NPIMap

Organization Active NPI

Mashantucket Pequot Tribal

Doing business as Pequot Health Care

  • Mail Order Pharmacy
  • Mashantucket, CT
National Provider Identifier
1578886461
Registry record updated Apr 1, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Mail Order PharmacyTaxonomy code 3336M0002X
License
285960015 Issued in CT
Legal business name
MASHANTUCKET PEQUOT TRIBAL
Doing business as
Pequot Health Care
Practice address
1 Annie George Dr
BLDG 1
Mashantucket, CT 06338-3801
Phone
(860) 396-6438
Fax
(800) 779-6329
NPI assigned
Mar 5, 2010
Last updated
Apr 1, 2011By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 1, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Edward MoldenhauerNPI 1992788962
Title
Director of Pharmacy Operation
Phone
(860) 396-2058

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Mail Order Pharmacy 3336M0002X 285960015 CT Primary

Addresses

Primary practice location

1 Annie George Dr
BLDG 1
Mashantucket, CT 06338-3801

Mailing address

1 Annie George Dr
PO Box 3559
Mashantucket, CT 06338-3801
Phone (860) 396-2058

Other identifiers 2

IdentifierTypeStateIssuer
004129210MedicaidCT
0721820OtherNCPDP PROVIDER IDENTIFICATION NUMBER

Other names 1

  • PEQUOT HEALTH CARE Doing business as

National Provider Directory

National Provider Directory
Tax ID family
Mashantucket Pequot Tri5 organizations share this tax ID, including this one

Other organizations with this tax ID 4

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

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1267747200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1301616000000",
    "number": "1578886461",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 ANNIE GEORGE DR",
            "address_2": "PO BOX 3559",
            "city": "MASHANTUCKET",
            "state": "CT",
            "postal_code": "063383801",
            "telephone_number": "860-396-2058",
            "fax_number": "860-396-6212"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 ANNIE GEORGE DR",
            "address_2": "BLDG 1",
            "city": "MASHANTUCKET",
            "state": "CT",
            "postal_code": "063383801",
            "telephone_number": "860-396-6438",
            "fax_number": "800-779-6329"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MASHANTUCKET PEQUOT TRIBAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2010-03-05",
        "last_updated": "2011-04-01",
        "status": "A",
        "authorized_official_last_name": "MOLDENHAUER",
        "authorized_official_first_name": "EDWARD",
        "authorized_official_title_or_position": "DIRECTOR OF PHARMACY OPERATION",
        "authorized_official_telephone_number": "860-396-2058"
    },
    "taxonomies": [
        {
            "code": "3336M0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Mail Order Pharmacy",
            "state": "CT",
            "license": "285960015",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004129210",
            "state": "CT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NCPDP PROVIDER IDENTIFICATION NUMBER",
            "identifier": "0721820",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "PEQUOT HEALTH CARE",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

Other providers in Mashantucket, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 1, 2011; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.