Dispenser/Prescriber Information

This page is for Dispenser/Prescriber information only

Dispenser/Prescriber First Name

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2. Dispenser/Prescriber First Name

Dispenser/Prescriber Last Name

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3. Dispenser/Prescriber Last Name

Dispenser/Prescriber PDMP Email (the email address where you would like to receive PDMP correspondence; can not be a shared or group inbox)

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4. Dispenser/Prescriber PDMP Email (the email address where you would like to receive PDMP correspondence; can not be a shared or group inbox)

Dispenser/Prescriber Licensure Email (the email address on file with the Nebraska Licensure Unit; only required if different than the PDMP email address listed above)

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5. Dispenser/Prescriber Licensure Email (the email address on file with the Nebraska Licensure Unit; only required if different than the PDMP email address listed above)

Dispenser/Prescriber Professional State License Number

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7. Dispenser/Prescriber Professional State License Number

Dispenser/Prescriber Last four digits of SSN*

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9. Dispenser/Prescriber Last four digits of SSN*

*This field is optional and is used to verify your credential issued by the Nebraska DHHS DPH Licensure Unit under the
Uniform Credentialing Act to verify eligibility for access to the Nebraska PDMP under Neb. Rev. Stat. ยง71-2454.
Dispenser/Prescriber Place of Birth

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10. Dispenser/Prescriber Place of Birth

Dispenser/Prescriber Facility Information

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11. Dispenser/Prescriber Facility Information

Are you authorizing any designees?

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12. Are you authorizing any designees?

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