Healthcare Provider Details

I. General information

NPI: 1497402895
Provider Name (Legal Business Name): MILES TYLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2022
Last Update Date: 03/04/2022
Certification Date: 03/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17521 ST LUKES WAY STE 120
CONROE TX
77384-8041
US

IV. Provider business mailing address

17521 ST LUKES WAY STE 120
CONROE TX
77384-8041
US

V. Phone/Fax

Practice location:
  • Phone: 936-207-4913
  • Fax:
Mailing address:
  • Phone: 936-207-4913
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: