Healthcare Provider Details

I. General information

NPI: 1003036435
Provider Name (Legal Business Name): MASHANTUCKET PEQUOT TRIBAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 04/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 ANNIE GEORGE DR
MASHANTUCKET CT
06338-3801
US

IV. Provider business mailing address

1 ANNIE GEORGE DR PO BOX 3559
MASHANTUCKET CT
06338-3801
US

V. Phone/Fax

Practice location:
  • Phone: 860-396-6438
  • Fax: 866-396-6212
Mailing address:
  • Phone: 860-369-2058
  • Fax: 860-396-6212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332800000X
TaxonomyIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
License NumberISH285960015
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3336M0002X
TaxonomyMail Order Pharmacy
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code3336M0003X
TaxonomyManaged Care Organization Pharmacy
License Number
License Number State

VIII. Authorized Official

Name: EDWARD MOLDENHAUER
Title or Position: DIRECTOR OF PHARMACY OPERATION
Credential: MS BS PHARM
Phone: 860-396-2058