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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