Pharmacy Contact Information Form (v3 July 28, 2015) – Nova Scotia Drug Information System Company Name Pharmacy Name & Store Number License Number Pharmacy Owner Pharmacy Manager Pharmacy Manager Email Address Pharmacy Telephone Number(s) (extension(s) if applicable) Pharmacy Fax Number Pharmacy Email Address(es) Preferred Contact Method ___ Fax (check all that apply) ___ Email Pharmacy Civic Address Pharmacy Mailing Address Pharmacy Hours Average Rx Fill per Week Pharmacy Software Vendor Target Go Live Date
Pharmacy Contact Information Form (v3 – July 28, 2015) Nova Scotia Drug Information System Company Name Pharmacy Name & Store Number License Number Pharmacy Owner Pharmacy Manager Pharmacy Manager Email Address Pharmacy Telephone Number(s) (extension(s) if applicable) Pharmacy Fax Number Pharmacy Email Address(es) Preferred Contact Method (check all that apply) ___ Fax ___ Email Pharmacy Civic Address Pharmacy Mailing Address Pharmacy Hours Average Rx Fill per Week Pharmacy Software Vendor Target Go Live Date
Pharmacy-Contact-Information-Form.docx