Medicine Shoppe #1401
653 Westwood Avenue
River Vale, NJ, 07675
Tel.: (201) 664-5553
Fax.: (201) 664-0905
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