Provider Demographics
NPI:1891837720
Name:FIESTA PHARMACY
Entity Type:Organization
Organization Name:FIESTA PHARMACY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHARMACIST
Authorized Official - Prefix:DR
Authorized Official - First Name:PRINCE
Authorized Official - Middle Name:C
Authorized Official - Last Name:NWAORGU
Authorized Official - Suffix:
Authorized Official - Credentials:
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:75227-6944
Mailing Address - Country:US
Mailing Address - Phone:214-275-8066
Mailing Address - Fax:214-275-7796
Practice Address - Street 1:6190 LYNDON B JOHNSON FWY
Practice Address - Street 2:SUITE #600
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-6344
Practice Address - Country:US
Practice Address - Phone:972-866-0017
Practice Address - Fax:972-866-0019
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX23938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX145505Medicaid