Organization
FIESTA LIFECARE PHARMACY 5 LLC
Active
Other names
Fiesta MLK Pharmacy, Fiesta Lifecare Pharmacy 5 LLC
Organization subpart
No
Provider details
NPI number
Authorized official
SIRISHA KANDI (PHARMACIST OWNER)
(972) 357-4477
Entity
Organization
Contact information
Practice address
3230 MARTIN LUTHER KING JR BLVD, DALLAS, TX 75210-2417
(214) 421-1067
(214) 426-7586
Mailing address
968 CONDOR DR, COPPELL, TX 75019-5985
(972) 357-4477
(214) 426-7586
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
31267
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
149805
—
TX
01
—
2164652
PK
—
Enumeration date
10/24/2016
Last updated
07/30/2020
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