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Contract Details
Facility name
Special Formula Prescriptions
Provider ID
P000002436
NPI
1568527711
Tax ID
631245959
Effective Date
4/15/2004
Last Updated
11/8/2016
Direct Contract
Yes
Status
Active
Contract Discounts
Discount Type
M
Exhibit ID
AM_105
AM_105
Location Details
Address
3918 Montclair Road Suite 203
Birmingham, AL 35213
United States
County
Jefferson
Phone
2058717445
(
Phone
)
Billing Details
Address
3918 Montclair Road
Suite 203
Birmingham, AL 35213
Billing Phone
2058717445
Specialty Type
Pharmacy
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Address