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3569 Business Center Dr, Suite 175 Pearland, TX 77584 Phone: (888) 489-0038 Fax: (877) 674-0389 08/08/2023 PA Approved - Transferred Prescriber: Adaeze Egesi Patient: Jared Tarver

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CVS Specialty Pharmacy (1-800-237-2767 OR 1-866-387-2573) YES Provider Network: 866-560-4042 (Options in order 5, 7) OR Pharmacy Customer Service 602-778-1800 (Options in order 5, 5) CHP All See Mercy Care YES See Mercy Care MOLINA HEALTHCARE Central Any contracted pharmacy YES Molina Contact Center: • Call 800-424-5891

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