Notification of Changes for Business Entity
General Information
Business Entity Name:	PREMIER PHARMACY BENEFIT MANAGEMENT, LLC
Incorporation / Formation Date:	04/19/2011
FEIN:	45-2392244
Ohio License Number:	948043
NPN:	16474446
DBA / Trade Name:
State of Domicile:	NC
County:	MECKLENBURG
Business Address
Address 1:	13034 BALLANTYNE CORPORATE PLACE
Address 2:
City:	CHARLOTTE
State:	NC
Zip:	28277
Phone:	704-816-4589
Fax:	704-816-4589
Business Web Site Address:	WWW.PREMIERINC.COM
Business Email Address:
Mailing Address
Address 1:	13034 BALLANTYNE CORPORATE PLACE
Address 2:
City:	CHARLOTTE
State:	NC
Zip:	28277
Indicate the type of change you are seeking
Address Change:	YES
Business Entity Name Change:	NO	Old Business Entity Name:
New DBA/Trade Name:	NO	New DBA/Trade Name:
Amend DBA/Trade Name:	NO	Old DBA/Trade Name:
Add/Delete Producers, Members, Owners, Partners, Officers and/or Directors:	NO

Licensed Producers
Name	Title	NPN	Add	Delete	Eff. Date

Members, Owners, Partners, Officers and Directors
Name	Title	Identifying #	Add	Delete	Eff. Date

Title Business Entities Only
1. Is any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance? (i.e. banking, auto dealer, mortgage company)	NO
2. Has any member, producer, owner, share holder, manager, partner, officer or director currently engaged in deriving income from or affiliated with (other than as a customer) any business or profession other than insurance since the filing of the previous CN-65 or the original application?	NO
3. If the answer to questions #1 or #2 is yes, identify the business or profession and the nature of person's involvement

Submitted By
Submitted By:	TAMMY PERRONE
Title:	DIRECTOR, SCS OPERATIONS
Phone Number:	704-816-5274
Email Address:	TAMMY_PERRONE@PREMIERINC.COM