Form 08-0098 - Wholesale Drug Distributor Self-Inspection Report - Alaska State Board Of Pharmacy
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4ALASKA STATE BOARD OF PHARMACY
WHOLESALE DRUG DISTRIBUTOR SELF-INSPECTION REPORT
PAGE 1 OF 4
Check Where Applicable
Official Name:
DBA Name:
Initial Application
Renewal
Address:
Change in Ownership
Telephone Number:
Change in Location
Fax Number:
Re-Inspection
Hours:
Wholesaler License Number
and Expiration:
Pharmacist Name and License
Number:
NOTE* Keep a copy of this report on file.
08-0098 (Rev. 5/98)
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