Single-page fax order form (PDF) for GLP-1 medication created/used by Dr. Babak Farzaneh. The form collects provider and patient details, shipping address, drug name/strength (Trizepatide 30mg/1ml), billing option, and is intended to be faxed to Fireside Pharmacy (fax: 1(760) 346-8725). Pharmacy contact: Arleen, support@firesidepharmacy.com, phone +1 (760) 346-113. Provider details on the form include Provider Name: Babak Farzaneh, DEA#: BF8819736, NPI#: 1740496322, and listed office phones.
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BF8819736
1740496322
2967 Michelson Dr. Unit S, Irvine CA 92612
Trizepatide 30mg / 1ml
1(760) 346-8725