Healthcare Provider Details

I. General information

NPI: 1386288868
Provider Name (Legal Business Name): FIESTA LIFECARE PHARMACY 8 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2019
Last Update Date: 10/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

412 E RILEY ST
FREER TX
75063
US

IV. Provider business mailing address

PO BOX 12929
SAN ANTONIO TX
78212-0929
US

V. Phone/Fax

Practice location:
  • Phone: 361-394-5151
  • Fax:
Mailing address:
  • Phone: 917-769-8014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: PREM KALIDINDI
Title or Position: MANAGER/OWNER
Credential:
Phone: 917-769-8014