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COMPLAINT DETAILS

PHARMACY NAME PHARMACIST/TECHNICIAN COMPLAINT IS AGAINST:
Address
City State Zip Phone
Explain the incident in your own words (Limit: 2000 characters)    Characters Used: 0

Complaint Filed By

First Name Middle Name Last Name Business Name
Address
City State Zip
Email Phone Alternate Phone

 
BY SUBMITTING THIS FORM YOU ATTEST THIS COMPLAINT TO BE TRUE AND FACTUAL