Example: marketing
Pharmacy Name Address 1 Address
Found 2 free book(s)
General Drug Prior Authorization Form Rational Drug ...
dhhr.wv.govPharmacy Name (if applicable) Pharmacy Address (Street) (City) (State) (Zip) Pharmacy 10-Digit NPI# Phone # (111-222-3333) Fax # (111-222-3333) Confidentiality Notice: This document contains confidential health information that is protected by law.
Chapter Phar 7
docs.legis.wisconsin.govThe name and address of the pharmacy to which it was transferred, the date and the first and last name of the pharmacist transferring the information are recorded on the invalidated pre-scription order or in a computer system meeting the requirements s. Phar 7.11 (2) (a).