Dispenser/Prescriber Information

This page is for Dispenser/Prescriber information only

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2. Dispenser/Prescriber First Name

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3. Dispenser/Prescriber Last Name

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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)

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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)

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7. Dispenser/Prescriber Professional State License Number

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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.

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10. Dispenser/Prescriber Place of Birth

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11. Dispenser/Prescriber Office Manager Name

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12. Dispenser/Prescriber Facility Name

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13. Dispenser/Prescriber Office Manager Email

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14. Dispenser/Prescriber Facility Phone Number (numbers only, no punctuation; i.e. 5551112222)

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15. Dispenser/Prescriber Facility Phone Number Extension (if applicable)

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16. Are you authorizing any designees?

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