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Patient closely monitored. PHYSICIAN If registered with CPAS only DEA/NPI/ID number is required. Registered Physician Covering Physician Physician s DEA/NPI/ID Number Physician s Signature Address Phone Number City State Zip Code Fax Number PHARMACIST If registered with CPAS only DEA/NPI/ID number is required. Pharmacy DEA/NPI/ID Number Pharmacist s Name Type or Print Title 2010 Mylan Pharmaceuticals Inc. White CPAS Yellow Pharmacy Pink Physician...

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