Secure Prescription Pads
Imprint Sheet
Imprint Sheet
We will
print the information exactly as submitted here.
Type
or print clearly.
|
Secure Prescription Pads Imprint Sheet |
We will
print the information exactly as submitted here.
Type
or print clearly. |
|
Group
Name |
|
Medical
Specialty |
|
Address |
|
City |
|
State |
|
Zip |
|
Telephone
No. |
|
Fax
No. |
| Physician
1 Name |
|||
| DEA
No |
Lic.
Number |
||
| NPI Number if required in your state | |||
| Physician
2 Name |
|||
| DEA
No |
Lic.
Number |
||
| NPI Number if required in your state | |||
| Physician
3 Name |
|||
| DEA
No |
Lic.
Number |
||
| NPI Number if required in your state | |||
Miscellaneous ___________________________________________________________________________________________ |
||
Mail
with order form to DRS Forms 24 Imperial Drive Selden, NY 1 1784 |
Fax
with order form to 1-631-696-4901 7/24 |
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