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HCA Order Form
Division South Atlantic Division
Site/Hospital Memorial Health
Billing Delivery
Name rellie.lorenzo@hcahealthcare.com Name Valerie Pittman
Email George.Greene1@healthtrustpg.com Email Valerie.Pittman@hcahealthcare.com
Address Line 1 Clinical Education Financial Reporting Address Line 1 One Meadows Parkway
Address Line 2 Clinical Education Financial Reporting Address Line 2
Address Line 3 Suite 1100 Address Line 3
City Nashville City Vidalia
State TN State GA
ZIP 37203 ZIP 30474
Items to Order
Code Description Quantity Total ($)
A99003 Brayden Power Adaptor for Adult & Baby, 110v, 8ft cord, U.S. Plug 1 $14.65
  Sub-Total $14.65