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T.D. Pharmacy Returns Form

    Please fill out the below form to begin the processing of your return:

Site Name:

Contact Name:

Site Address:

DEA #:

Phone #:

Fax #:

Email Address:

Wholesaler Name:

Wholesaler Address:

Wholesale Account Number:

Wholesale Debit Memo #:


NDC number (No Dashes):
Drug Name / Strength:
Package Size:
DEA Class:
Full Packages:
Additional Partial:

Item List:
No Items

When you click Submit, you will receive an email confirmation of your selections.

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