Organization
MASHANTUCKET PEQUOT TRIBAL
Active
Other names
PEQUOT HEALTH CARE
Organization subpart
No
Provider details
NPI number
Authorized official
EDWARD MOLDENHAUER (DIRECTOR OF PHARMACY OPERATION)
(860) 396-2058
Entity
Organization
Contact information
Practice address
1 ANNIE GEORGE DR, BLDG 1, MASHANTUCKET, CT 06338-3801
(860) 396-6438
(800) 779-6329
Mailing address
1 ANNIE GEORGE DR, PO BOX 3559, MASHANTUCKET, CT 06338-3801
(860) 396-2058
(860) 396-6212
Taxonomy
Speciality
Code
Description
License number
State
3336M0002X
Mail Order Pharmacy
Primary
285960015
CT
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004129210
—
CT
01
—
0721820
NCPDP PROVIDER IDENTIFICATION NUMBER
—
Enumeration date
03/05/2010
Last updated
04/01/2011
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