Get Quest Pharmaceuticals Inc Retail Pharmacy Questionnaire 2011-2026

This guide provides a step-by-step approach to completing the Quest Pharmaceuticals Inc Retail Pharmacy Questionnaire online. With clear instructions and helpful tips, users can easily navigate through the form to ensure accurate submission.

Follow the steps to complete the questionnaire efficiently.

1. Press the ‘Get Form’ button to obtain the questionnaire and open it in your preferred editor.
2. Begin by filling out the pharmacy name in the designated field, including any doing business as (dba) name if applicable.
3. Indicate if the pharmacy has ever operated under a different name by selecting 'Yes' or 'No' and, if 'Yes,' providing the previous name.
4. Enter the pharmacy's address, including the city, state, and zip code.
5. Fill in the pharmacy phone number and fax number, ensuring all contact information is accurate.
6. Provide the pharmacy email address for any further communication.
7. List the name of the pharmacist in charge and the person responsible for purchasing.
8. Indicate whether the pharmacy has a website by selecting 'Yes' or 'No,' and if 'Yes,' provide the web address.
9. Answer if the pharmacy is affiliated with any other pharmacy or internet website by selecting 'Yes' or 'No,' and describe any affiliations if applicable.
10. Indicate the number of years the owner has operated the pharmacy and the number of years at the current address.
11. Specify whether the owner is a licensed pharmacist by selecting 'Yes' or 'No.'
12. Fill in the pharmacy DEA registration number and expiration date, and attach a copy of the registration.
13. Indicate if the pharmacy has ever had a DEA registration or license suspended or revoked and provide details if applicable.
14. Complete the state Board of Pharmacy registration number and attach a copy of the registration.
15. Answer if the pharmacy has other licensure or registration. If 'Yes,' provide copies of the documents.
16. Estimate the percentage of the pharmacy’s prescriptions that are for controlled substances.
17. List all controlled drug suppliers currently used by the pharmacy.
18. Indicate if any supplier has limited the amount of controlled substance products purchasable by the pharmacy, and provide the name and reason for the limit if applicable.
19. Provide the names and DEA numbers of the largest prescribing physicians associated with the pharmacy.
20. Specify the services the pharmacy provides by checking all applicable options such as nursing homes, long term care facilities, hospice, and pain management clinics.
21. If needed, attach additional pages to include further comments or information about your pharmacy.
22. Confirm the completion of the form by signing, dating, and printing your full name and title.
23. Once the questionnaire is fully completed, save changes, and download the form to retain a copy for your records before faxing it along with the required documentation.

Complete your Quest Pharmaceuticals Inc Retail Pharmacy Questionnaire online today to ensure accurate and timely processing.