Provider Demographics
NPI:1386288868
Name:FIESTA LIFECARE PHARMACY 8 LLC
Entity type:Organization
Organization Name:FIESTA LIFECARE PHARMACY 8 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PREM
Authorized Official - Middle Name:
Authorized Official - Last Name:KALIDINDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-769-8014
Mailing Address - Street 1:PO BOX 12929
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-0929
Mailing Address - Country:US
Mailing Address - Phone:917-769-8014
Mailing Address - Fax:
Practice Address - Street 1:412 E RILEY ST
Practice Address - Street 2:
Practice Address - City:FREER
Practice Address - State:TX
Practice Address - Zip Code:75063
Practice Address - Country:US
Practice Address - Phone:361-394-5151
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-29
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy