Medicine Shoppe #0879
30 West Marin Street
Palmyra, PA, 17078
Tel.: (717) 838-6355
Fax.: (717) 832-0728
Request a refill for your medication(s)
Please note that this form allows you to submit up to 5 prescriptions for refill. If you would like to submit more than 5 prescriptions for refill, please complete additional submission forms.

*

Rx Number(s)

Numbers only
NO letters or dashes