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4. A list of Member s legal affiliates that will purchase PROVENGE through the GPO selected above including name address phone number Lead Physician Name Lead Physician DEA Number NPI and Health Industry Number HIN has been attached to this Declaration Form. Key Contact at Practice Key Contact Signature Key Contact Phone Practice Name Street Address City / State / Zip DEA Number HIN Number NPI Number Current GPO Affiliation for Provenge IF ANY Please return this completed form by fax to ION...

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