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Provider Name P. O. Box 12345 Dallas TX 55555 555 555-1234 Pay To Name Pay To Address City State Pay To ID BXXXX XBXBX 123456789 020510 123 Paradise Road Smith Bob A. 06041936 San Antonio M TX 77777-1234 WeCare Insurance Company P. O. Box 98765 Harrisburg PA 11111-0101 Pharmacy Med-Sur Supplies Emergency Call Min Total Charges 99282 25 40. 25 10. 25 100. 00 115. 75 266. 25 123456 Y WeCare Option I 1423568798 Brown B3 282N00000X IG B12345 John. 06041936 San Antonio M TX 77777-1234 WeCare...
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