Items in bold are required.
"Participant" means a practitioner....
License or Permit Number: License Type: Nurse Practitioner Pharmacy Physician Physician Assistant
Facility Name:
Contact Person:
Telephone Number: (ex. 7015551212) Extension: Email Address:
Address Where Drugs Are to Be Shipped/Stored
Street Address:
City: State: AL AK AB AZ AR AE AP AA BC CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MB MD MA MI MN MS MO MT NE NV NB NH NJ NM NY NF NC ND NT NS NS OH OK ON OR PA PE PR QC RI SK SA SC SD TN TX AE UT VT VI VA WA WV WI WY YT Zip: (ex. 12345 or 12345-6789)
Before being dispensed...
Records of distribution and dispensing must include: a. Name and address of participant b. Drug or device name