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General NPI Number Information
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NPI Number | 1104377332
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Entity Type | Organization
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Legal Business Name | FIESTA LIFECARE PHARMACY 5 LLC
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Dates
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Enumeration Date | 10/24/2016
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Last Update Date | 07/30/2020
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Provider Practice Location Address
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Address Line | 3230 MARTIN LUTHER KING JR BLVD
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City | DALLAS
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State | TX
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Zip | 75210-2417
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Country | US
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Telephone | 214-421-1067
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Fax | 214-426-7586
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Provider Business Mailing Address
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Address Line | 968 CONDOR DR
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City | COPPELL
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State | TX
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Zip | 75019-5985
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Country | US
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Telephone | 972-357-4477
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Fax | 214-426-7586
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Authorized Official
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Title or Position | PHARMACIST OWNER
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Name | SIRISHA KANDI
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Credential |
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Telephone | 972-357-4477
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336C0003X
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Taxonomy Name | Community/Retail Pharmacy
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License Number | 31267
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License Number State | TX
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