NPIMap

Mashantucket Pequot Tribal

Organization Active NPI Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy · Mashantucket, CT

NPI 1003036435 · NPPES record last updated Apr 1, 2011

Key facts

NPI
1003036435
Entity type
Organization (NPI type 2)
Primary specialty
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy 332800000X
License
ISH285960015 (CT)
Legal business name
MASHANTUCKET PEQUOT TRIBAL
Practice address
1 Annie George Dr
Mashantucket, CT 06338-3801
Phone
(860) 396-6438
Fax
(866) 396-6212
NPI assigned
Apr 26, 2007
Organization subpart
No

Authorized official

Name
Edward Moldenhauer, MS BS PHARM
Title
Director of Pharmacy Operation
Phone
(860) 396-2058

Corporate family (same tax ID) 4

Organizations that report the same tax identification number in the National Provider Directory.

National Provider Directory

Tax ID family
Mashantucket Pequot Tribal Nation Health Center (5 organizations share this tax ID)

Specialties & licenses

Specialty (taxonomy)CodeLicenseStatePrimary
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy 332800000X ISH285960015 CT Yes
Pharmacy 333600000X
Mail Order Pharmacy 3336M0002X
Managed Care Organization Pharmacy 3336M0003X

Addresses

Primary practice location

1 Annie George Dr
Mashantucket, CT 06338-3801

Mailing address

1 Annie George Dr
PO Box 3559
Mashantucket, CT 06338-3801
Phone (860) 369-2058

Other identifiers

IdentifierTypeStateIssuer
004129210MedicaidCT
0718619OtherNCPDP PROVIDER IDENTIFICATION NUMBER

Other names

  • PEQUOT HEALTH CARE Doing business as

Other providers in Mashantucket, CT

All providers in Mashantucket, CT · Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy in Connecticut

Sources for this page

Verify at the official NPI Registry.