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General NPI Number Information
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NPI Number | 1174065643
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Entity Type | Organization
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Legal Business Name | FIESTA LIFECARE PHARMACY 3 LLC
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Dates
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Enumeration Date | 11/15/2016
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Last Update Date | 12/13/2019
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Provider Practice Location Address
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Address Line | 707 23RD ST SUITE F
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City | GALVESTON
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State | TX
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Zip | 77550
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Country | US
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Telephone | 409-877-7029
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Fax | 281-549-5957
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Provider Business Mailing Address
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Address Line | 707 23RD ST SUITE F
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City | GALVESTON
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State | TX
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Zip | 77550
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Country | US
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Telephone | 409-877-7029
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Fax | 281-549-5957
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Authorized Official
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Title or Position | OFFICER
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Name | PREM KALIDINDI
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Credential |
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Telephone | 917-769-8014
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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 | 31265
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License Number State | TX
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