Prescription Transfer

Personal Information

Full Name *
Date of Birth *
Phone Number *
EMail

Address

Address Line 1
Address Line 2
City
Postal / Zip Code
Country
Pharmacy Name *
Pharmacy Number *

Insurance Information (Optional)

Cardholder's Name
Cardholder ID
Agency Name
BIN
PCN

Prescription To Be Transferred

If you woould like to transfer all prescriptions, simply check the below box
Transfer all of my Prescription
List Specific Prescriptions to be transferred

Type your medication name in the first box below, then input your prescription number from your current pharmacy in the second box
Blue Pharm. 1 Med Name
Blue Pharm. 1 #
Blue Pharm. 2 Med Name
Blue Pharm. 2 #
Blue Pharm. 3 Med Name
Blue Pharm. 3 #
Blue Pharm. 4 Med Name
Blue Pharm. 4 #
Blue Pharm. 5 Med Name
Blue Pharm. 5 #
EMPLOYMENT OPPORTUNITIES
Send resume to: jagesh.benzer@rxinstant.com
CONTACT US
6240 Michigan Ave.
Detroit, MI 48210
Available TIME
?Hours: 9:00am � 6:00pm M-F
10:00am � 2:00pm Saturday
REFILL ORDER
refill online24 *7
call us at (313) 899-4120