Order - ASRX

A RUSH can be applied at any time and will be shipped in 3-5 business days for a fee. You can find the order confirmation sent via e-mail. View pricing here

California RX New Order

Please use reorder form if you have ordered from us before!

Step 1 of 2

Number of Providers*
425 Rx size can hold up to 8 providers and locations. 800 Rx size can hold up to 15 providers and locations. 850 Rx size can hold up to 30 providers and locations.
Number of Locations
Print NPI Number on Pad?
- Yes
Print Fax Number on Pad?
- Yes
Provider Name (Include Title)*
DEA Number*
For multiple DEA numbers separate each with a slash eg. AB1234567 / XB1234567
License Number*
NPI Number
Provider Name
DEA Number
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Location Name
Phone*
Fax
Address*
City*
State*
Zipcode*
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