Basic Information
| Provider Information | |||||||||
| NPI: | 1952895633 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HARRIS TEETER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HARRIS TEETER #311 | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 842772 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022842772 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 324 VILLAGE WALK DR | ||||||||
| Address2: | |||||||||
| City: | HOLLY SPRINGS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275407683 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9999999999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2018 | ||||||||
| LastUpdateDate: | 06/18/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WARMAN | ||||||||
| AuthorizedOfficialFirstName: | JESSIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER OF LICENSING | ||||||||
| AuthorizedOfficialTelephone: | 5137621019 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 3336C0003X | Y | Suppliers | Pharmacy | Community/Retail Pharmacy |
No ID Information.