NPIMap

Organization Active NPI

Mashantucket Pequot Tribal

Doing business as Pequot Health Care

  • Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
  • Mashantucket, CT
National Provider Identifier
1720024524
Registry record updated Apr 16, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Indian Health Service/Tribal/Urban Indian Health (I/T/U) PharmacyTaxonomy code 332800000X
Legal business name
MASHANTUCKET PEQUOT TRIBAL
Doing business as
Pequot Health Care
Practice address
1 Annie George Drive
BLDG 1
Mashantucket, CT 06338-3801
Phone
(860) 396-6435
Fax
(800) 779-6329
NPI assigned
Jun 21, 2006
Last updated
Apr 16, 2025By the provider in NPPES
Organization subpart
Yes
Parent organization
MASHANTUCKET PEQUOT TRIBALAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 16, 2025

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

Authorized official

Name
Dr. John Grossomanides, PHARMD, RPH
Title
Director of Pharmacy Services
Phone
(860) 396-6435

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Pharmacy 333600000X
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy 332800000X Primary
Mail Order Pharmacy 3336M0002X

Addresses

Primary practice location

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

Mailing address

1 Annie George Drive
BLDG 1
Mashantucket, CT 06338-3801
Phone (860) 396-6435

Other identifiers 2

IdentifierTypeStateIssuer
004129210MedicaidCT
2000351OtherPK

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
Part of
Mashantucket Pequot Tri

Other organizations with this tax ID 4

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

Practitioners & affiliated clinicians

Practitioners 1

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": "1150848000000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1744761600000",
    "number": "1720024524",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1 ANNIE GEORGE DRIVE",
            "address_2": "BLDG 1",
            "city": "MASHANTUCKET",
            "state": "CT",
            "postal_code": "063383801",
            "telephone_number": "860-396-6435",
            "fax_number": "860-396-6212"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1 ANNIE GEORGE DRIVE",
            "address_2": "BLDG 1",
            "city": "MASHANTUCKET",
            "state": "CT",
            "postal_code": "063383801",
            "telephone_number": "860-396-6435",
            "fax_number": "800-779-6329"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "MASHANTUCKET PEQUOT TRIBAL",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "MASHANTUCKET PEQUOT TRIBAL",
        "enumeration_date": "2006-06-21",
        "last_updated": "2025-04-16",
        "status": "A",
        "authorized_official_last_name": "GROSSOMANIDES",
        "authorized_official_first_name": "JOHN",
        "authorized_official_title_or_position": "DIRECTOR OF PHARMACY SERVICES",
        "authorized_official_telephone_number": "860-396-6435",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "PHARMD, RPH"
    },
    "taxonomies": [
        {
            "code": "333600000X",
            "taxonomy_group": "",
            "desc": "Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "332800000X",
            "taxonomy_group": "",
            "desc": "Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "3336M0002X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Mail Order Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "004129210",
            "state": "CT"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PK",
            "identifier": "2000351",
            "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 16, 2025; 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.