*Patient Gender Code: 0 = Not Specified. 1 = Male. 2 = Female *Patient Relationship Code. 0 = Not Specified. 1 = Cardholder. 2 = Spouse. 3 = Child. 4 = Other *Pharmacy Name and Address - complete name and address of pharmacy/provider . Service Provider ID/QUAL - The NPI number of the provider submitting the claim. Service Provider ID Qualifier ....