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Organization
MASHANTUCKET PEQUOT TRIBAL
Active
Organization
MASHANTUCKET PEQUOT TRIBAL
Active
Parent organization
MASHANTUCKET PEQUOT TRIBAL
Other names
PEQUOT HEALTH CARE
Organization subpart
Yes
Provider details
NPI number
Legal business name
MASHANTUCKET PEQUOT TRIBAL
Authorized official
DR. JOHN GROSSOMANIDES PHARMD, RPH (DIRECTOR OF PHARMACY SERVICES)
(860) 396-6435
Entity
Organization
Contact information
Practice address
1 ANNIE GEORGE DRIVE, BLDG 1, MASHANTUCKET, CT 06338-3801
(860) 396-6435
(800) 779-6329
Mailing address
1 ANNIE GEORGE DRIVE, BLDG 1, MASHANTUCKET, CT 06338-3801
(860) 396-6435
(860) 396-6212
Taxonomy
Speciality
Code
Description
License number
State
332800000X
Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Primary
—
—
333600000X
Pharmacy
—
—
3336M0002X
Mail Order Pharmacy
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004129210
—
CT
01
—
2000351
PK
—
Enumeration date
06/21/2006
Last updated
04/16/2025
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