Healthcare Provider Details

I. General information

NPI: 1174065643
Provider Name (Legal Business Name): FIESTA LIFECARE PHARMACY 3 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 12/13/2019
Certification Date: 12/13/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 23RD ST SUITE F
GALVESTON TX
77550
US

IV. Provider business mailing address

707 23RD ST SUITE F
GALVESTON TX
77550
US

V. Phone/Fax

Practice location:
  • Phone: 409-877-7029
  • Fax: 281-549-5957
Mailing address:
  • Phone: 409-877-7029
  • Fax: 281-549-5957

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code3336C0003X
TaxonomyCommunity/Retail Pharmacy
License Number31265
License Number StateTX

VIII. Authorized Official

Name: PREM KALIDINDI
Title or Position: OFFICER
Credential:
Phone: 917-769-8014