MEDICARE: FIESTA LIFECARE PHARMACY 4 LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	333600000X	Pharmacy
2	3336C0003X	Community/Retail Pharmacy	31266	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2164063	OTHER		PK
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1356883821
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIESTA LIFECARE PHARMACY 4 LLC

Provider Business Mailing Address
First Line	:	PO BOX 631670
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75063
Country	:	US
Telephone Number	:	210-881-0890
Fax Number	:	210-564-6969

Provider Business Practice Location Address
First Line	:	4202 PIONEER RD
Second Line	:
City	:	BALCH SPRINGS
State	:	TX
Zip	:	75180-3537
Country	:	US
Telephone Number	:	972-557-3535
Fax Number	:	972-557-4187

Authorized Official
Title or Position	:	BOARD MEMBER
Name	:	PREM KALIDINDI
Credential	:
Telephone Number	:	917-769-8014

Provider Enumeration Date	:	11/15/2016
Last Update Date	:	09/19/2025

Similar Medicare Providers

1053497982 — RLS SUPERMARKETS LLC
Practice Location Address:

4202 PIONEER RD
BALCH SPRINGS, TX
75180-3537

Practice Phone: 972-557-3535
Practice Fax: 972-557-4187

1558937219 — MEGAN SKEET DNP, CPNP-PC
Practice Location Address:

4041 E SAN MIGUEL ST
COLORADO SPRINGS, CO
80909-3537

Practice Phone: 719-632-5700
Practice Fax:

1922406131 — JACQUELINE ELIZABETH LOESCH RDH
Practice Location Address:

4041 E SAN MIGUEL ST
COLORADO SPRINGS, CO
80909-3537

Practice Phone: 719-632-5700
Practice Fax: 719-344-7880

1134601149 — BRANDI HICKS DNP, NP-C
Practice Location Address:

4041 E SAN MIGUEL ST
COLORADO SPRINGS, CO
80909-3537

Practice Phone: 719-344-7846
Practice Fax:

1629258058 — DALLAS GERIATRICS ASSOCIATES, P.A
Practice Location Address:

4200 SHEPHERD LN
BALCH SPRINGS, TX
75180-3423

Practice Phone: 214-325-1969
Practice Fax: 972-291-0019

1386632750 — BALCH SPRINGS NURSING HOME, L.P.
Practice Location Address:

4200 SHEPHERD LN
BALCH SPRINGS, TX
75180-3423

Practice Phone: 972-286-0335
Practice Fax: 972-286-7514

Directions to “FIESTA LIFECARE PHARMACY 4 LLC ” Practice Location

Language	Start Address	Practice Location

These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

Copyright © 2007-2026 (Powered by Swiss Vault Engine), all rights reserved. HIPAA liability, trademark, document use and software licensing rules apply. All registered trademarks, used in the content, are the property of their owners. Your interactions with this site are in accordance with our Terms of Use and Privacy Policy.