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T.D. Pharmacy Returns Form
Please fill out the below form to begin the processing of your return:
Site Name:
Contact Name:
Site Address:
DEA #:
Phone #:
Fax #:
Email Address:
Wholesaler Name:
Wholesaler Address:
Wholesale Account Number:
Wholesale Debit Memo #:
Comments:
NDC number (No Dashes):
Drug Name / Strength:
Package Size:
DEA Class:
2
3-N
3
4
5
NA
Lot:
Exp:
Full Packages:
Additional Partial:
Item List:
No Items
When you click Submit, you will receive an email confirmation of your selections.
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