NAME*
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ADDRESS
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Rx #
		(located in upper left corner of label)
DELIVERY METHOD		Pick-Up Delivered to address above Mail to this address

RX REFILL

Please note: You have chosen to have your prescription refilled at

Herbst Pharmacy
710 W. Main St.
Greentown, IN 46936

Please allow our pharmacy a minimum of one hour before pick-up at this location.