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FOR OFFICIAL USE ONLYECLRS:___EMAILED: ___1728 GRAND ISLAND BLVD GRAND ISLAND, NY 14072 NPI: 1 8 8 4 0 CIA #D2184418Phone: (716)77Fax: (716)77CHESTER FOX, MD.MEDICAL DIRECTORCOVID19 ANTIGEN / RT PCR
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This form is used to report prescription drug information to the authorities.
Pharmacies and other healthcare providers are required to file this form.
The form should be filled out with accurate prescription drug information.
The purpose is to monitor prescription drug usage and prevent misuse.
Information such as prescription drug name, dosage, and patient details must be reported.
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