Missouri Department of Health and Senior Services

1. Name, address and DEA number of the supplier. 2. Name, address and DEA number of the receiver (No DEA# for LTCFs) 3. Date of the transfer. 4. Name, strength, dosage form and quantity of the drug(s) transferred. If both parties have a copy of this document, it can serve as a transfer document for the supplier and also a receipt record for the ... ................
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