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Pharmacy Robbery Report Form

Name of Pharmacy 

Pharmacist in Charge

Physical Address

 City State   Zip

Date of Robbery    Estimated Time of Robbery

Estimated Cost of Stolen Inventory   Estimated Cost of Pharmacy Damage

Please provide an estimate of inventory that was stolen (e.g. 2 pints of promethazine with codeine).

Please remember to report all pharmacy break-ins to your local law enforcement, the Arkansas State Board of Pharmacy, and the DEA (when appropriate).


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