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					Prescription Medication Patient Assistance Program Application Form

Prescriptions for controlled drugs can only be accepted directly from your physicians office.

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Prescription Medication Patient Assistance Program Application Form

NICOLE 222 BARKSDALE

CORMIER

XBX - 26323-7055 BROUSSARD 02/08/1972 337-330-2862 INSPIRE2@YMAIL.COM 600 3 LA Female 70518 436-19-4836

ADDERALL XR

Copyright © 2008 Xubex Inc. All Rights Reserved.Xubex is a division of MCS Enterprises

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Prescription Medication Patient Assistance Program Application Form

Copyright © 2008 Xubex Inc. All Rights Reserved.Xubex is a division of MCS Enterprises

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