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Get AZ Prescriber/Dispenser Database Access Request Form

T FORM New Update Terminate Please print or type, and use full name ( first, middle initial, last, suffix ( Jr., Sr., II, III, etc. ) ) Full Name: SSN: DOB: Professional Title RPH MD DO DDS DMD DPM NP PA OD ND NMD HMD State Board License Number / Expiration Date DEA Number / Expiration Date Email Address: Facility Name: Facility Address: City / County: State / Zip Code: Phone Number: Fax Number: Proposed Password: ( Must contain at least 8 characters: at least 1 capital l.

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