Andee Plaza

We welcome prescription transfers from any pharmacy. To TRANSFER a prescription, please fill out the following form and submit.

First Name:

Middle Name:

Last Name:

Date of Birth:

Allergies:

Phone:

Address:

City:

State:

ZIP / Postal Code:

Pharmacy Name:

Pharmacy Phone:

Pharmacy Fax:

Card-Holder's First Name:

Card-Holder's Last Name:

Card-Holder's name:

BIN:

PCN:

Group Line:

If you would like to TRANSFER all prescriptions, simply check the box below.

TRANSFER all my prescriptions

If you would like to selectively TRANSFER your prescriptions, simply start typing
to find your medication.

Rx1:

RX 1 #:

Rx2:

RX 2 #:

Rx3:

RX 3 #:

Rx4:

RX 4 #:

Rx5:

RX 5 #:

TRANSFER RX