Common Contracts

DRUG MEDI-CAL PROVIDER AGREEMENT

Medi-Cal Provider Agreement • May 5th, 2020 • California

• Contract Type
  Medi-Cal Provider Agreement
• Filed
  May 5th, 2020
• Jurisdiction
  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)*