Provider Demographics
NPI:1326313677
Name:MOHEGAN TRIBE OF INDIANS OF CT
Entity Type:Organization
Organization Name:MOHEGAN TRIBE OF INDIANS OF CT
Other - Org Name:MOHEGAN PHARMACY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DEPUTY CHIEF OF STAFF, OPS&ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:MAXEINER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-862-6343
Mailing Address - Street 1:67 SANDY DESERT RD
Mailing Address - Street 2:
Mailing Address - City:UNCASVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06382-1111
Mailing Address - Country:US
Mailing Address - Phone:855-664-4679
Mailing Address - Fax:860-862-9099
Practice Address - Street 1:67 SANDY DESERT RD
Practice Address - Street 2:
Practice Address - City:UNCASVILLE
Practice Address - State:CT
Practice Address - Zip Code:06382-1111
Practice Address - Country:US
Practice Address - Phone:855-664-4679
Practice Address - Fax:860-862-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-20
Last Update Date:2019-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTPCY.0001934332800000X
KS22-102271332800000X
DCNRX0000432332800000X
COOSP.0006230332800000X
MO2013044792332800000X
MS14964/7.1332800000X
LAPHY.007550-NR332800000X
GAPHNR001180332800000X
FLPH26952332800000X
AL114286332800000X
IL54.018477332800000X
MTPHA-MOP-LIC-25328332800000X
HIPMP-959332800000X
CANRP-1530332800000X
MEMO40001384332800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2135247OtherPK