Provider Demographics
NPI:1447907787
Name:WOODLANDS SUPREME LLC
Entity type:Organization
Organization Name:WOODLANDS SUPREME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MILES
Authorized Official - Middle Name:
Authorized Official - Last Name:TYLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-616-1982
Mailing Address - Street 1:23503 GOLDKING CROSS CT
Mailing Address - Street 2:
Mailing Address - City:SPRING
Mailing Address - State:TX
Mailing Address - Zip Code:77373-8627
Mailing Address - Country:US
Mailing Address - Phone:832-616-1982
Mailing Address - Fax:
Practice Address - Street 1:17521 ST LUKES WAY STE 120
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77384-8041
Practice Address - Country:US
Practice Address - Phone:936-207-4913
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy