Provider Demographics
NPI:1720024524
Name:MASHANTUCKET PEQUOT TRIBAL
Entity type:Organization
Organization Name:MASHANTUCKET PEQUOT TRIBAL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF PHARMACY SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:GROSSOMANIDES
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD, RPH
Authorized Official - Phone:860-396-6435
Mailing Address - Street 1:1 ANNIE GEORGE DRIVE
Mailing Address - Street 2:BLDG 1
Mailing Address - City:MASHANTUCKET
Mailing Address - State:CT
Mailing Address - Zip Code:06338-3801
Mailing Address - Country:US
Mailing Address - Phone:860-396-6435
Mailing Address - Fax:860-396-6212
Practice Address - Street 1:1 ANNIE GEORGE DRIVE
Practice Address - Street 2:BLDG 1
Practice Address - City:MASHANTUCKET
Practice Address - State:CT
Practice Address - Zip Code:06338-3801
Practice Address - Country:US
Practice Address - Phone:860-396-6435
Practice Address - Fax:800-779-6329
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MASHANTUCKET PEQUOT TRIBAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-21
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332800000XSuppliersIndian Health Service/Tribal/Urban Indian Health (I/T/U) Pharmacy
No333600000XSuppliersPharmacy
No3336M0002XSuppliersPharmacyMail Order Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004129210Medicaid
2000351OtherPK