CONTROLLED SUBSTANCES INVENTORY LOG - NCBOP

1 CONTROLLED SUBSTANCES INVENTORY LOG Name of Pharmacy: _____ Address: _____ City: _____ State: _____ Zip Code: _____ Name of REGISTRANT on DEA Registration: _____ DEA Registration Number: _____ Date of INVENTORY : _____ INVENTORY Taken At: Opening of Business Closing of Business OR Time Started: _____ Time Ended: _____ _____ Signature of Person Responsible for Taking INVENTORY _____ Print Name of Person Responsible for Taking INVENTORY CII INVENTORY for _____ Date: ____/_____/_____ Pharmacy Page | 1 Drug Description Sch Pkg SizeDose UnitNDC On Hand Quantity ACTIQ LONZENGE 1200 MCG 2 30 LOZ 63459-0512-30 ACTIQ LONZENGE1600 MCG230 LOZ63459-0516-30 ACTIQ LONZENGE 400 MCG 2 100 LOS 63459-0504-30 ADDERALL 10 MG2100 TAB57844-0110-01 ADDERALL 15 MG 2 100 TAB 57844-0115-01 ADDERALL 20 MG 2100 TAB57844-0120-01 ADDERALL 30 MG2100 TAB57844-0130-01 ADDERALL XR CAP 10 MG 2 100 CAP 54092-0383-01 ADDERALL XR CAP 15 MG2100 CAP54092-0385-01 ADDERALL XR CAP 20 MG 2 100 CAP 54092-0387-01 ADDERALL XR CAP 25 MG 2100 CAP54092-0389-01 ADDERALL XR CAP 30 MG 2 100 CAP 54092-0391-01 ADDERALL XR CAP 5 MG 2100 CAP54092-0381-01 ADHANSIA XR CAP 25 MG 230

2 CAP72912-0525-30 ADHANSIA XR CAP 35 MG 2 30 CAP 72912-0535-30 ADHANSIA XR CAP 45 MG 230 CAP72912-0545-30 ADHANSIA XR CAP 55 MG 2 30 CAP 72912-0555-30 ADHANSIA XR CAP 70 MG 230 CAP72912-0570-30 ADHANSIA XR CAP 85 MG 2 30 CAP 72912-0585-30 ADZENYS ER ORAL ML2ML70165-0003-15 ADZENYS XR ODT TAB MG 230 TAB70165-0020-30 ADZENYS XR ODT TAB MG 2 30 TAB 70165-0025-30 ADZENYS XR ODT TAB MG 230 TAB70165-0030-30 ADZENYS XR ODT TAB MG 2 30 TAB 70165-0005-30 ADZENYS XR ODT TAB MG 230 TAB70165-0010-30 ADZENYS XR ODT TAB MG 230 TAB70165-0015-30 AMPHET IR TAB 10 MG 2100 TAB69238-1564-01 AMPHET IR TAB 5 MG2100 TAB69238-1563-01 AMPHET SALTS ER CAP 10 MG 2 100 CAP 00115-1487-01 AMPHET SALTS ER CAP 15 MG 2100 CAP00115-1488-01 AMPHET SALTS ER CAP 15 MG 2 100 CAP 00228-3063-11 Write-in Items Not Listed Above2 22 222 22 22222 CII INVENTORY for _____ Date.

3 ____/_____/_____ Pharmacy Page | 2 Drug DescriptionSch Pkg SizeDose UnitNDCOn Hand QuantityAMPHET SALTS ER CAP 20 MG 2 100 CAP 00115-1489-01 AMPHET SALTS ER CAP 20 MG 2100 CAP00781-2352-01 AMPHET SALTS ER CAP 20 MG 2 100 CAP 00228-3060-11 AMPHET SALTS ER CAP 25 MG 2100 CAP00115-1490-01 AMPHET SALTS ER CAP 30 MG 2 100 CAP 00115-1491-01 AMPHET SALTS ER CAP 5 MG 2100 CAP00115-1486-01 AMPHET SALTS TAB 10 MG2100 TAB00406-8892-01 AMPHET SALTS TAB 10 MG 2 100 TAB 00555-0972-02 AMPHET SALTS TAB 10 MG 2100 TAB68382-0952-01 AMPHET SALTS TAB MG 2 100 TAB 68382-0953-01 AMPHET SALTS TAB 15 MG 2100 TAB00406-8885-01 AMPHET SALTS TAB 15 MG 2 100 TAB 00555-0777-02 AMPHET SALTS TAB 15 MG 2100 TAB68382-0954-01 AMPHET SALTS TAB 20 MG 2100 TAB00406-8893-01 AMPHET SALTS TAB 20 MG 2 100 TAB 00555-0973-02 AMPHET SALTS TAB 20 MG 2100 TAB68382-0955-01 AMPHET SALTS TAB 30 MG 2 100 TAB 00406-8894-01 AMPHET SALTS TAB 30 MG 2100 TAB00555-0974-02 AMPHET SALTS TAB 30 MG 2 100 TAB 68382-0956-01 AMPHET SALTS TAB 5 MG 2100 TAB68382-0950-01 AMPHET SALTS TAB MG 2100 TAB68382-0951-01 APTENSIO XR CAP 10 MG 2 90 CAP 42858-0401-45 APTENSIO XR CAP 15 MG 290 CAP42858-0402-45 APTENSIO XR CAP 20 MG 2 90 CAP 42858-0403-45 APTENSIO XR CAP 30 MG290 CAP42858-0404-45 APTENSIO XR CAP 40 MG290 CAP42858-0405-45 APTENSIO XR CAP 50 MG290 CAP42858-0406-45 APTENSIO XR CAP 60 MG290 CAP42858-0407-45 BELLADONNA & OPIUM MG 2 SUP

4 00574-7045-12 BELLADONNA & OPIUM MG 2 SUP00574-7040-12 CODEINE SULFATE TAB 30 MG 2 100 TAB 00527-1698-01 CODEINE SULFATE TAB 30 MG 2100 TAB00054-0244-25 Write-in Items Not Listed Above22 222 22 22222 CII INVENTORY for _____ Date: ____/_____/_____ Pharmacy Page | 3 Drug DescriptionSch Pkg SizeDose UnitNDCOn Hand QuantityCONCERTA TAB 18 MG 2 100 TAB 50458-0585-01 CONCERTA TAB 27 MG 2100 TAB50458-0588-01 CONCERTA TAB 36 MG 2 100 TAB 50458-0586-01 CONCERTA TAB 54 MG 2100 TAB50458-0587-01 COTEMPLA XR ODT TAB MG 2 30 TAB 70165-0200-30 COTEMPLA XR ODT TAB MG 230 TAB70165-0300-30 COTEMPLA XR ODT TAB MG 230 TAB70165-0100-30 DAYTRANA 10 MG 2 30 TAB 68968-5552-03 DAYTRANA 15 MG 230 TAB68968-5553-03 DAYTRANA 20 MG 2 30 TAB 68968-5554-03 DAYTRANA 30 MG 230 TAB68968-5555-03 DEXEDRINE SPAN CAP 10 MG 2 90 TAB 64896-0674-10 DEXEDRINE SPAN CAP 15 MG 290 TAB64896-0675-10 DEXMETHYLPHENIDATE

5 HCL ER CAP 10 MG 2100 CAP00527-8107-37 DEXMETHYLPHENIDATE HCL ER CAP 15 MG 2 100 CAP 00527-8108-37 DEXMETHYLPHENIDATE HCL ER CAP 15 MG2100 CAP00093-5552-01 DEXMETHYLPHENIDATE HCL ER CAP 20 MG 2 100 CAP 00527-8109-37 DEXMETHYLPHENIDATE HCL ER CAP 25 MG 2100 CAP00527-8110-37 DEXMETHYLPHENIDATE HCL ER CAP 30 MG 2 100 CAP 00527-8111-37 DEXMETHYLPHENIDATE HCL ER CAP 35 MG 2100 CAP00527-8112-37 DEXMETHYLPHENIDATE HCL ER CAP 40 MG 2100 CAP49884-0546-01 DEXMETHYLPHENIDATE HCL ER CAP 5 MG 2 100 CAP 00527-8106-37 DEXMETHYLPHENIDATE HCL TAB 10 MG 2100 TAB10702-0108-01 DEXMETHYLPHENIDATE HCL TAB 10 MG 2 100 TAB 27808-0093-01 DEXMETHYLPHENIDATE HCL TAB MG 2100 TAB10702-0106-01 DEXMETHYLPHENIDATE HCL TAB 5 MG 2100 TAB10702-0107-01 DEXTROAMPHETAMINE SULF ER CAP 10MG2100 CAP00406-8961-01 DEXTROAMPHETAMINE SULF ER CAP 10MG290 CAP00115-9928-10 DEXTROAMPHETAMINE SULF ER CAP 15MG 2 100 CAP 00406-8962-01 DEXTROAMPHETAMINE SULF ER CAP 15MG290 CAP00115-9929-10 DEXTROAMPHETAMINE SULF ER CAP 5 MG 2 100 CAP 00406-8960-01 DEXTROAMPHETAMINE SULF IR TAB 10 MG 2100 TAB00406-8959-01 Write-in Items Not Listed Above22 222 22 22222 CII INVENTORY for _____ Date.

6 ____/_____/_____ Pharmacy Page | 4 Drug DescriptionSch Pkg SizeDose UnitNDCOn Hand QuantityDEXTROAMPHETAMINE SULF SOL 5MG/5ML 2 ML 27808-0085-01 DEXTROAMPHETAMINE SULF TAB 10 MG 2100 TAB10702-0066-01 DEXTROAMPHETAMINE SULF TAB 5 MG 2 100 TAB 10702-0065-01 DILAUDID TAB 4 MG 2100 TAB42858-0234-01 DILAUDID TAB 8 MG 2 100 TAB 42858-0338-01 DURAGESIC TRANSDERM SYS 100 MCG/HR 25 PAT50458-0106-05 DURAGESIC TRANSDERM SYS 12 MCG/HR 25 PAT50458-0101-05 DURAGESIC TRANSDERM SYS 25 MCG/HR 2 5 PAT 50458-0102-05 DURAGESIC TRANSDERM SYS 50 MCG/HR 25 PAT50458-0104-05 DURAGESIC TRANSDERM SYS 75 MCG/HR 2 5 PAT 50458-0105-05 DYANAVEL XR ORAL SUSP 2ML27808-0102-01 EMBEDA CAP 100/4 MG 2 30 CAP 60793-0437-20 EMBEDA CAP 20 MG 230 CAP60793-0430-20 EMBEDA CAP 30 MG 230 CAP60793-0431-20 EMBEDA CAP 50 MG 2 30 CAP 60793-0433-20 EMBEDA CAP 60 MG 230 CAP60793-0434-20 EMBEDA CAP 80 MG 2 30 CAP 60793-0435-20 ENDOCET TAB 10/325 MG 2100 TAB60951-0712-70 ENDOCET TAB 5/325 MG 2 100 TAB 60951-0602-70 EVEKEO ODT TAB 10 MG 230 TAB24338-0033-01 EVEKEO ODT TAB 15 MG 230 TAB243380-0350-1 EVEKEO ODT TAB 20 MG 2 30 TAB 24338-0037-02 EVEKEO TAB 10 MG2100 TAB24338-0026-10 EVEKEO TAB 5 MG 100 2 100 TAB 24338-0022-10 FENTANYL CIT ORAL TRANS 1200 MCG 230 PAT00406-9212-30 FENTANYL CIT ORAL TRANS 1600 MCG230 PAT00406-9216-30 FENTANYL CIT ORAL TRANS 200 MCG 230 PAT00406-9202-30 FENTANYL CIT ORAL TRANS 400 MCG 230 PAT00406-9204-30

7 FENTANYL CIT ORAL TRANS 600 MCG 2 30 PAT 00406-9206-30 FENTANYL CIT ORAL TRANS 800 MCG 230 PAT00093-7868-65 FENTANYL CIT ORAL TRANS 800 MCG 2 30 PAT 00406-9208-30 FENTANYL CIT VIAL 50 MCG/ML 2 ML 2ML00641-6027-25 Write-in Items Not Listed Above22 222 22 22222 CII INVENTORY for _____ Date: ____/_____/_____ Pharmacy Page | 5 Drug DescriptionSch Pkg SizeDose UnitNDCOn Hand QuantityFENTANYL TR SYS MATRIX 100 MCG/HR 2 5 PAT 60505-7009-02 FENTANYL TR SYS MATRIX 100 MCG/HR25 PAT00406-9000-76 FENTANYL TR SYS MATRIX 100 MCG/HR 2 5 PAT 60505-7084-02 FENTANYL TR SYS MATRIX 12 MCG/HR 25 PAT60505-7080-02 FENTANYL TR SYS MATRIX 25 MCG/HR 2 5 PAT 60505-7081-02 FENTANYL TR SYS MATRIX 25 MCG/HR25 PAT00406-9025-76 FENTANYL TR SYS MATRIX MCG/HR25 PAT60505-7085-02 FENTANYL TR SYS MATRIX 50 MCG/HR 2 5 PAT 60505-7082-02 FENTANYL TR SYS MATRIX 50 MCG/HR 25 PAT00406-9050-76 FENTANYL TR SYS MATRIX MCG/HR 2 5 PAT 00378-9126-98 FENTANYL TR SYS MATRIX 75 MCG/HR 25

8 PAT60505-7083-02 FENTANYL TR SYS MATRIX 75 MCG/HR 2 5 PAT 00406-9075-76 FENTANYL TR SYS MATRIX MCG/HR 25 PAT00378-9127-98 FENTORA TAB 400 MCG 228 TAB63459-0544-28 FOCALIN TAB 10MG 2 100 TAB 00078-0382-05 FOCALIN TAB 2100 TAB00078-0380-05 FOCALIN TAB 5MG 2 100 TAB 00078-0381-05 FOCALIN XR CAP 10 MG 2100 CAP00078-0431-05 FOCALIN XR CAP 15 MG 2 100 CAP 00078-0493-05 FOCALIN XR CAP 20 MG 2100 CAP00078-0432-05 FOCALIN XR CAP 25 MG2100 CAP00078-0608-05 FOCALIN XR CAP 30 MG 2 90 CAP 00078-0433-05 FOCALIN XR CAP 35 MG 290 CAP00078-0609-05 FOCALIN XR CAP 40 MG 2 90 CAP 00078-0434-05 FOCALIN XR CAP 5 MG 290 CAP00078-0430-05 HYDROCODONE APAP SOL 2ML66689-0023-04 HYDROCODONE APAP SOL 2ML00121-0772-16 HYDROCODONE APAP SOL 2ML66689-0023-16 HYDROCODONE BIT/APAP TAB 10/300 MG 2 100 TAB 00406-0378-01 HYDROCODONE BIT/APAP TAB 10/325 MG 2100 TAB31722-0943-01 HYDROCODONE BIT/APAP TAB 10/325 MG 2 100 TAB 10702-0191-01 HYDROCODONE BIT/APAP TAB 10/325 MG 2100 TAB00406-0125-01 Write-in Items Not Listed Above22 222 22 22222 CII INVENTORY for _____ Date.

9 ____/_____/_____ Pharmacy Page | 6 Drug DescriptionSch Pkg SizeDose UnitNDCOn Hand QuantityHYDROCODONE BIT/APAP TAB 10/325 MG 2 100 TAB 00254-2036-01 HYDROCODONE BIT/APAP TAB 10/325 MG 21000 TAB10702-0191-10 HYDROCODONE BIT/APAP TAB 10/325 MG 2 1000 TAB 00603-3887-32 HYDROCODONE BIT/APAP TAB 10/325 MG 2500 TAB31722-0943-05 HYDROCODONE BIT/APAP TAB 10/325 MG 2 500 TAB 10702-0191-50 HYDROCODONE BIT/APAP TAB 5/300 MG 2100 TAB00406-0376-01 HYDROCODONE BIT/APAP TAB 5/325 MG 2100 TAB31722-0941-01 HYDROCODONE BIT/APAP TAB 5/325 MG 2 100 TAB 10702-0189-01 HYDROCODONE BIT/APAP TAB 5/325 MG 21000 TAB27808-0035-03 HYDROCODONE BIT/APAP TAB 5/325 MG 2 500 TAB 31722-0941-05 HYDROCODONE BIT/APAP TAB 5/325 MG 2500 TAB10702-0189-50 HYDROCODONE BIT/APAP TAB MG 2 100 TAB 00406-0377-01 HYDROCODONE BIT/APAP TAB MG 2100 TAB27808-0115-01 HYDROCODONE BIT/APAP TAB MG 2100 TAB31722-0942-01 HYDROCODONE BIT/APAP TAB MG 2 100 TAB 10702-0190-01 HYDROCODONE BIT/APAP TAB MG 2100 TAB00406-0124-01 HYDROCODONE BIT/APAP TAB MG 2 1000 TAB 10702-0190-10 HYDROCODONE BIT/APAP TAB MG 2500 TAB31722-0942-05 HYDROCODONE BIT/APAP TAB MG 2 500 TAB 10702-0190-50 HYDROCODONE BIT/HOM MBR TAB 5 BIT/HOM MBR TAB 5 230 TAB10702-0055-03 HYDROCODONE BIT/IBUPR TAB 10/200 MG 2 100 TAB 53746-0117-01 HYDROCODONE BIT/IBUPR TAB 5/200 MG 2100 TAB53746-0146-01 HYDROCODONE BIT/IBUPR TAB MG 2 500 TAB 00603-3897-28 HYDROCODONE

10 BIT/IBUPR TAB 2100 TAB53746-0145-01 HYDROCODONE BIT/IBUPR TAB 2100 TAB00603-3897-21 HYDROCODCHLOR/POLI ER SUSP 118ML 2ML62542-0301-04 HYDROCOD CHLOR/POLI ER SUSP 473 ML 2ML62542-0301-17 HYDROCODONE/APAP TAB MG 2 100 TAB 65162-0115-10 HYDROCODONE/APAP TAB MG 2500 TAB65162-0115-50 HYDROCOD/HOMATROP SYR 5 2 ML 50383-0043-16 HYDROMORPHONE HCL ER TAB 12 MG 2100 TAB13811-0702-10 Write-in Items Not Listed Above22 222 22 22222 CII INVENTORY for _____ Date: ____/_____/_____