Home Phone Number
Cell Phone Number
Value Drug Account Number
Type of Location
UrbanSuburbanRuralShopping CenterStand Alone BuildingClinic
Competitors (How many and what Kind, Chains, independents, distance from store)
Square Footage (Front-end, Pharmacy and Storage Area)
Staff (Pharmacists, Techs, Other, Any Speciality Personal: Surgical Fitters, Etc.)
Property (Own or Lease)
If Lease, Term Remaining: (Years/Months)
Prescription Volume: (Weekly RX Count Volumen/Annual Dollar Volume)
Reason for Proposed Sale
Best Method for Contacting You
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