Medicine Shoppe #1009
1890 Capitol Street NE
Salem, OR, 97303
Tel.: (503) 364-4436
Fax.: (503) 364-5103
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