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Transfer Your Prescription
If you are human, leave this field blank.
Please enter the information for the pharmacy transferring from below.
Pharmacy Name
Pharmacy Phone Number
City
State
SC
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Patient Information
First Name
Last Name
Date of Birth
Phone Number
Email
List Medications (required) & Rx Numbers (optional)
Do not use child-resistant packaging
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