Organization
FIESTA LIFECARE PHARMACY 4 LLC
Active
Other names
Fiesta Lifecare Pharmacy 4, LLC
Organization subpart
No
Provider details
NPI number
Authorized official
PREM KALIDINDI (BOARD MEMBER)
(917) 769-8014
Entity
Organization
Contact information
Practice address
4202 PIONEER RD, BALCH SPRINGS, TX 75180-3537
(972) 557-3535
(972) 557-4187
Mailing address
PO BOX 631670, IRVING, TX 75063
(210) 881-0890
(210) 564-6969
Taxonomy
Speciality
Code
Description
License number
State
333600000X
Pharmacy
—
—
3336C0003X
Community/Retail Pharmacy
Primary
31266
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
149595
—
TX
01
—
2164063
PK
—
Enumeration date
11/15/2016
Last updated
09/19/2025
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