Dispenser Uploader Information

* Facility Type (select one of the following)

* Upload method (select one of the following)

* Uploader First Name

* Uploader Last Name

* Uploader Address

* Uploader City

* Uploader State

* Uploader Zip Code

* Uploader Telephone

* 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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