Provider Demographics
NPI:1720529852
Name:PRESTIGE ONE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:PRESTIGE ONE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:JAMAL
Authorized Official - Last Name:JOHNA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-543-5649
Mailing Address - Street 1:1108 GULF FWY S
Mailing Address - Street 2:SUITE #270
Mailing Address - City:LEAGUE CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77573-5100
Mailing Address - Country:US
Mailing Address - Phone:713-893-3073
Mailing Address - Fax:
Practice Address - Street 1:1108 GULF FWY S
Practice Address - Street 2:SUITE #270
Practice Address - City:LEAGUE CITY
Practice Address - State:TX
Practice Address - Zip Code:77573-5100
Practice Address - Country:US
Practice Address - Phone:713-893-3073
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-08
Last Update Date:2017-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies