Provider Demographics
NPI:1184340481
Name:MILES SAMUEL, MIRA R
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:R
Last Name:MILES SAMUEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14411 GADSHILL CIR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77044-4917
Mailing Address - Country:US
Mailing Address - Phone:281-770-0353
Mailing Address - Fax:
Practice Address - Street 1:8484 CENTRAL MALL DR
Practice Address - Street 2:
Practice Address - City:PORT ARTHUR
Practice Address - State:TX
Practice Address - Zip Code:77642-8001
Practice Address - Country:US
Practice Address - Phone:409-722-3392
Practice Address - Fax:409-722-2038
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-18
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX37240183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist