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North Dakota-Western Plains Public Health - Payment - IN OFFICE

701-667-3370
403 Burlington St. Mandan ND 58554
Pay Location Code 38625

Name

Daytime Contact Phone Number (including dashes, ie 123-456-7890)

Purpose of Payment

Payment Type

Cardholder Phone

Payment Amount

Fee Amount (Non Refundable): $0.00 Total Amount: $0.00

First Name

Last Name

Billing Address

City

State

Zip

Account Type

Routing Number

Account Number

Card Number

Exp Date

CVV

Terms and conditions

Customer Accepts