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Get Exactus Pharmacy Solutions Prescription Order Form

Ient Name: Date of Birth: Gender: r Male r Female Shipping Address: City: State: Zip: Phone Number: Allergies: r No Known r Aspirin r Codeine r r Peanuts r Sulfa r Other Prescription Information Fax the completed form from the provider office. This is not valid for CII prescriptions. Please make sure the quantity is for a 90-day supply unless otherwise noted. Our Promise: We will never auto-ship medications and will verify all prescriptions with member before shipping.

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Keywords relevant to Exactus Pharmacy Solutions Prescription Order Form

  • CII
  • npi
  • fda
  • WellCare2012NA
  • DAW
  • 90-day
  • equivalents
  • Dissemination
  • applicable
  • codeine
  • sulfa
  • eng
  • refills
  • MD
  • governed
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