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1) Pharmacy Information
Select the pharmacy name that this refill is on file with.
Pharmacy: 
 
2) Prescription Information
Enter the prescription number(s) and the last name on the prescription. If you have more than one prescription with different last names, select fill prescriptions for multiple people below. Be sure to enter name exactly as it appears on prescription label.

Patient's Last Name
  Prescription Number
1 2
3 4
5 6
7 8
 
3) Phone Number
Enter a phone number,including area code, so our pharmacist can contact you if there is a problem with this order. Example:xxx-xxx-xxxx
Phone Number:
 
Would you like to:

Would you like the pharmacy to contact your doctor
if your prescription needs authorization?

   Please allow 20 to 30 seconds for  your prescriptions to process.