Provider Demographics
NPI:1730283706
Name:FIESTA PHARMACY
Entity Type:Organization
Organization Name:FIESTA PHARMACY
Other - Org Name:BUCKNER VILLAGE PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:
Authorized Official - Last Name:OKONKWO
Authorized Official - Suffix:
Authorized Official - Credentials:RPH
Authorized Official - Phone:214-275-8066
Mailing Address - Street 1:2947 S BUCKNER BLVD
Mailing Address - Street 2:SUITE #500
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75227-6952
Mailing Address - Country:US
Mailing Address - Phone:214-275-8066
Mailing Address - Fax:214-275-7796
Practice Address - Street 1:2947 S BUCKNER BLVD
Practice Address - Street 2:STE 500
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-6952
Practice Address - Country:US
Practice Address - Phone:214-275-8066
Practice Address - Fax:214-275-7796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X
TX239143336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145505Medicaid
2099573OtherPK