Pharmacy Services
Client Information Packet Request

If you are responsible for pharmacy staffing and would like to find out about the services we offer, please complete the on-line form below and we would be happy to send you an information packet. If you should have any questions or concerns, please don't hesitate to contact us.

Pharmacy Information  
Pharmacy Name:
Branch: 
Address 1: 
Address 2: 
City: 
State:
Zip: 
Business type:  Corporation Partnership Sole Owner
Other, please specify:
Pharmacy Type:  Retail Hospital Mail Order LTC/Nursing Home 
Other, please specify:
Contact Information  
Salutation:  Mr. Mrs. Ms. Dr.
Last Name: 
First name: 
Middle initial: 
Position/Job Title: 
Phone:  Ext:
FAX: 
E-Mail: 
Comments: 

I am an authorized representative of this pharmacy and I evaluate, recommend, authorize or approve the staffing needs for this pharmacy.

 
Pharmacy Services
Pharmacists
Pharmacy Technician
Staffing

If you'd rather not send this information electronically, please feel free to print, complete, sign and FAX it to us at: 

(818) 907-9239
Temporary

OR
short and long term
Call us at:
(818) 907-9009
(877) Rx.Rx.Rx3
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Last modified: April 20, 2005