Common Contracts
1 similar Provider Agreement contracts
ARIZONA VACCINES FOR CHILDREN (VFC) PROGRAM 2017 PROVIDER AGREEMENTProvider Agreement • October 19th, 2020
FACILITY INFORMATIONFacility Name: RED ROCK PEDIATRICS VFC Pin#: 1755 Facility Address: 800 COVE PARKWAY City: COTTONWOOD County: YAVAPAI State: AZ Zip: 86326 Telephone: (928)649-3003 Fax: (928)649-3030 Shipping Address(if different than facility address): 800 COVE PARKWAY City: COTTONWOOD County: YAVAPAIMEDICAL DIRECTOR OR EQUIVALENT State: AZ Zip: 86326 Instructions: The official VFC registered health care provider signing the agreement must be a practitioner authorized to administer pediatric vaccines under state law who will also be held accountable for compliance by the entire organization and its VFC providers with the responsible conditions outlined in the provider enrollment agreement. The individual listed here must sign the provider agreement. Last Name, First, MI: TUCCILLE, WENDY, Title:MD Specialty: Pediatrics License No.: AZ29432 Medicaid or NPI No.: 1700948098 Employer Identification No.:(optional): Provide Information for second individual as needed: Last Name, Firs
