1356883821 NPI number — FIESTA LIFECARE PHARMACY 4 LLC

Table of content: (NPI 1356883821)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356883821 NPI number — FIESTA LIFECARE PHARMACY 4 LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIESTA LIFECARE PHARMACY 4 LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FIESTA LIFECARE PHARMACY 4, LLC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356883821
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/27/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 631670
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVING
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75063
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-881-0890
Provider Business Mailing Address Fax Number:
210-564-6969

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4202 PIONEER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BALCH SPRINGS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75180-3537
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
972-557-3535
Provider Business Practice Location Address Fax Number:
972-557-4187
Provider Enumeration Date:
11/15/2016

Additional Information

Authorized Official

Authorized Official Last Name:
KALIDINDI
Authorized Official First Name:
PREM
Authorized Official Middle Name:
Authorized Official Title or Position:
BOARD MEMBER
Authorized Official Telephone Number:
917-769-8014

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 31266 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2164063 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 149595 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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