OFDTK-54230

    ORAL FLUID DRUG TEST KIT REQUEST FORM ACCT#54230

    ORDERING PROVIDER INFORMATION

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    Name: Shawn Hamm

    NPI:1821330895

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    Name: Lauren McClairen

    NPI: 1457886129

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    Name: Ankitkumar Patel

    NPI: 1104001122

    Address: 3327 Research Plaza, Suite 108, San Antonio, TX 78235

    Phone: (210) 423-3950

    Name: Ankitkumar Patel

    NPI: 1104001122

    Address: 3903 Wiseman Blvd, Ste 101, San Antonio, TX 78251

    Phone: (210) 681-6474

    Name: Allison Stock

    NPI: 1619314564

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    Name: Shelby Husband

    NPI: 1821725052

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    Name: Amber Gordon

    NPI: 1992443873

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    Name: Adam Nanaa

    NPI: 1225767130

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    Name: Lauren Bell

    NPI: 1285168914

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    Name: Jacob Bezold

    NPI: 1821651282

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    Name: Emily Hahn

    NPI: 1811190796

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    Name: Kira Reich

    NPI: 1407485964

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    Name: Lisa Scarvey

    NPI: 1487638102

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    Name: Cacilda Faria-Siega

    NPI: 1780806117

    Address: 2863 US 45 Bypass, 2nd FL, Jackson, TN 38305

    PATIENT INFORMATION

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    *DOB:

    *GENDER: MALEFEMALE

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    PRESCRIBED MEDICATION

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    Brand

    Generic

    PATIENT INSURANCE

    *PATIENT HAVE INSURANCE
    YESNO

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    *PATIENT RELATIONSHIP TO INSURED

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    ORDERING PHYSICIAN INFORMATION

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