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Get NY DOH-3848 2013

Nt to PHL Article 33 within 30 days of June 30 and December 31, each year. Retain a copy for your records. Reporting Period January 1- June 30, _____ Agency Name NYS-EMS ID No. Address City Name of DEA Registrant DEA License No. Name of Controlled Substance July 1 -- December 31, _____ NYS-BCS License No. State Name of Controlled Substance Zip Business Phone Day Phone Name of Controlled Substance Dosage Form (mg/ unit) Total Quantity Received from DEA Registrant Total Quantity Ad.

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