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Get USScript Pharmacy Price Inquiry Form 2014-2024

: MAC Pricing usscript.com / Fax: 866-912-0334 * Indicates Required Field ** There may be a delay if not provided ***Actual Claim Processed Policy Please check one: st 1 request 2 nd request Claim Information: *Rx Number: *Date of Fill: Pharmacy Information: *Contact Person: *NCPDP # (7 Digits) *Chain/PSAO ID # (3 Digits) *Pharmacy Name: *Phone: **Fax: *City: *Zip: **Email: *State: Drug Information *Drug name and strength: *NDC# (12 Digits) *Dosage form: **Metric quantity.

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