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Organization
MASHANTUCKET PEQUOT TRIBAL
Active
Organization
MASHANTUCKET PEQUOT TRIBAL
Active
Other names
PEQUOT HEALTH CARE
Organization subpart
No
Provider details
NPI number
Authorized official
EDWARD MOLDENHAUER MS BS PHARM (DIRECTOR OF PHARMACY OPERATION)
(860) 396-2058
Entity
Organization
Contact information
Practice address
1 ANNIE GEORGE DR, MASHANTUCKET, CT 06338-3801
(860) 396-6438
(866) 396-6212
Mailing address
1 ANNIE GEORGE DR, PO BOX 3559, MASHANTUCKET, CT 06338-3801
(860) 369-2058
(860) 396-6212
Taxonomy
Speciality
Code
Description
License number
State
332800000X
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Primary
ISH285960015
CT
333600000X
Pharmacy
—
—
3336M0002X
Mail Order Pharmacy
—
—
3336M0003X
Managed Care Organization Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004129210
—
CT
01
—
0718619
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
04/26/2007
Last updated
04/01/2011
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