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General NPI Number Information
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NPI Number | 1720024524
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Entity Type | Organization
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Legal Business Name | MASHANTUCKET PEQUOT TRIBAL
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Dates
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Enumeration Date | 06/21/2006
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Last Update Date | 04/16/2025
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Provider Practice Location Address
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Address Line | 1 ANNIE GEORGE DRIVE BLDG 1
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City | MASHANTUCKET
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State | CT
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Zip | 06338-3801
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Country | US
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Telephone | 860-396-6435
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Fax | 800-779-6329
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Provider Business Mailing Address
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Address Line | 1 ANNIE GEORGE DRIVE BLDG 1
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City | MASHANTUCKET
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State | CT
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Zip | 06338-3801
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Country | US
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Telephone | 860-396-6435
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Fax | 860-396-6212
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Authorized Official
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Title or Position | DIRECTOR OF PHARMACY SERVICES
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Name | DR. JOHN GROSSOMANIDES
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Credential | PHARMD, RPH
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Telephone | 860-396-6435
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 333600000X
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Taxonomy Name | Pharmacy
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3336M0002X
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Taxonomy Name | Mail Order Pharmacy
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 332800000X
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Taxonomy Name | Indian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
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License Number |
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License Number State |
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