Provider Demographics
NPI:1174065643
Name:FIESTA LIFECARE PHARMACY 3 LLC
Entity type:Organization
Organization Name:FIESTA LIFECARE PHARMACY 3 LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PREM
Authorized Official - Middle Name:
Authorized Official - Last Name:KALIDINDI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:917-769-8014
Mailing Address - Street 1:707 23RD ST
Mailing Address - Street 2:SUITE F
Mailing Address - City:GALVESTON
Mailing Address - State:TX
Mailing Address - Zip Code:77550
Mailing Address - Country:US
Mailing Address - Phone:409-877-7029
Mailing Address - Fax:281-549-5957
Practice Address - Street 1:707 23RD ST
Practice Address - Street 2:SUITE F
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77550
Practice Address - Country:US
Practice Address - Phone:409-877-7029
Practice Address - Fax:281-549-5957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-15
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX312653336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX150052Medicaid
2164062OtherPK
TX14594Medicaid