Dispenser Uploader Information
Facility Type (select one of the following)

Question Title

* Facility Type (select one of the following)

Upload method (select one of the following)
*if unsure please contact your software vendor for clarification

Question Title

* Upload method (select one of the following)
*if unsure please contact your software vendor for clarification

Uploader First Name

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* Uploader First Name

Uploader Last Name

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* Uploader Last Name

Uploader Address

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* Uploader Address

Uploader City

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* Uploader City

Uploader State

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* Uploader State

Uploader Zip Code

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* Uploader Zip Code

Uploader Telephone

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* Uploader Telephone

Uploader Email*

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* Uploader Email*

*Only one email per uploader account to receive error reports
Please contact NeHII Support with questions regarding this form at PDMP@nehii.org, phone:  1-866-978-1799,
or fax:  1-866-550-6007

Select Next to enter pharmacy-specific information

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