Common Contracts
2 similar Drug Medi-Cal Provider Agreement contracts
DRUG MEDI-CAL PROVIDER AGREEMENTDrug Medi-Cal Provider Agreement • May 5th, 2020 • California
Legal name of applicant or provider Business name (if different than legal name) Provider number (NPI) Business Telephone Number Business address (number, street) City State ZIP code (9-digit) Mailing address (number, street, P.O. Box number) City State ZIP code (9-digit) Previous business address (number, street) City State ZIP code (9-digit) Taxpayer Identification Number (TIN)*
DRUG MEDI-CAL PROVIDER AGREEMENTDrug Medi-Cal Provider Agreement • September 8th, 2014 • California
Date Legal name of applicant or provider Business name (if different than legal name) Provider number (NPI ) Business telephone number( ) Business address (number, street) City State ZIP code (nine-digit) Mailing address (number, street, P.O. Box number) City State ZIP code (nine-digit) Previous business address (number, street) City State ZIP code (nine-digit)
