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T sign the form. 3. Fax, mail or email this form to the NDPDMP office at 701-328-9536 or ndbophpdmp btinet.net. For Office Use Only Date Rec d: ND #: Phar Name of Pharmacy License or Permit Number Approved Mailing Address/Physical Address Denied Mailing Address/Physical Address City Response/Notes: State Zip/Postal Code Name of Pharmacist In Charged or Compliance Point of Contact Telephone Fax Email I attest that the information provided is accurate to the best of my knowledge.

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