Provider Demographics
NPI:1003036435
Name:MASHANTUCKET PEQUOT TRIBAL
Entity Type:Organization
Organization Name:MASHANTUCKET PEQUOT TRIBAL
Other - Org Name:PEQUOT HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF PHARMACY OPERATION
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:
Authorized Official - Last Name:MOLDENHAUER
Authorized Official - Suffix:
Authorized Official - Credentials:MS BS PHARM
Authorized Official - Phone:860-396-2058
Mailing Address - Street 1:1 ANNIE GEORGE DR
Mailing Address - Street 2:PO BOX 3559
Mailing Address - City:MASHANTUCKET
Mailing Address - State:CT
Mailing Address - Zip Code:06338-3801
Mailing Address - Country:US
Mailing Address - Phone:860-369-2058
Mailing Address - Fax:860-396-6212
Practice Address - Street 1:1 ANNIE GEORGE DR
Practice Address - Street 2:
Practice Address - City:MASHANTUCKET
Practice Address - State:CT
Practice Address - Zip Code:06338-3801
Practice Address - Country:US
Practice Address - Phone:860-396-6438
Practice Address - Fax:866-396-6212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-26
Last Update Date:2011-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTISH285960015332800000X
333600000X, 3336M0002X, 3336M0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
No3336M0003XSuppliersPharmacyManaged Care Organization Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004129210Medicaid
0718619OtherNCPDP PROVIDER IDENTIFICATION NUMBER