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Get Direct Dispensing Log Veterinary

STATE OF CALIFORNIA DEPARTMENT OF JUSTICE DIRECT DISPENSING LOG Veterinary Use Only BNE 5/04 Veterinarian/Dispenser Name Veterinary Lic. Address Telephone DEA Date of Dispensing Client First Name Numeric Quantity MI Client Address Drug Name State Zip NDC Number Animal Patient s Name Client Gender Code Male 1/Female 2 Strength of Rx Client Date of Birth City Reporting Month/Year / Date submitted // Mail to CURES Program P.

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