Application For Registration
With The Pharmacy Board
As A Dispensing Physician
1. | 2. |
Name and Address of Dispensing Physician | Affix Dispensing Label Here |
3. Physician's North Carolina License Number ______________________________
4. Are you currently practicing in a professional association registered with the North Carolina Medical Board?
______ Yes ______ No. If yes, enter the name and registration number of the professional corporation:
______________________________________________________________________
______________________________________________________________________
5. I certify that the information is correct and complete.
________________________ | _________________ |
Signature | Date |
N.C. Gen. Stat. § 90-85.21