Date Wholesaler Hospital Name Address
Stocking Request City/State/Zip Code Safecor Health GPO Unit-Dose Products Wholesaler Name/Local DC Wholesaler Account Number(s) Dear Wholesaler: My Contact Name/Title On behalf of my pharmacy/health system, I am requesting that you stock the following NEW My Phone
unit-dose products by Safecor Health at my local My Email servicing distribution center. I have checked the items below that I want you to stock locally and DEA#
have provided an estimated monthly usage. Whole. Acct. Mgr. Name Thank you. Acct. Mgr. Phone/Email
Check All the Items Unit-Dose Estimated Safecor Health You Want Your Local NEW Safecor Health Unit-Dose Product Name Strength & Dosage Quantities Monthly Usage NDC# DC to Stock Per Box (No. of Boxes)
Benzocaine/Menthol Sore Throat Lozenge 15 mg/3.6 mg 48433-111-01 100
Calcium Antacid Chewable Tab 500 mg 48433-106-01 100 (compare to Tums) Fruit Flavor Calcium Antacid Chewable Tab 750 mg 48433-107-01 100 (compare to Tums) Berry Flavor
Calcium with Vitamin D Tablet 600 mg/400 IU 48433-105-01 100
Docusate Sodium 250 mg Softgel 250 mg 48433-101-01 100
Docusate Sodium Liquid Unit-Dose Cups 100 mg/10 mL 48433-205-10 40
Docusate Sodium Syrup Unit-Dose Cups 100 mg/25 mL 48433-207-25 40
Fish Oil (Omega-3) Softgel 1000 mg 48433-110-01 100
Mineral Oil USP Unit-Dose Cups 30 mL 48433-202-30 40
Prenatal Multivitamins with Iron Tablets N/A 48433-112-01 100
Regular Strength Antacid Unit-Dose Cups 30 mL 48433-204-30 40
Senna Syrup Unit-Dose Cups 8.8 mg/5 mL 48433-211-05 40
Vitamin B-1 Tablet (Thiamine) 100 mg 48433-108-01 100
Vitamin D3 Tablet (Cholecalciferol) 400 IU 48433-109-01 100
Vitamin D3 Tablet (Cholecalciferol) 1000 IU 48433-104-01 100
Safecor Health Estimated Monthly Other Products Strength & Dosage NDC# Bottle Size Usage (No. of Bottles) 23.4% (234 mg/mL) Sodium Chloride Oral Solution Concentrated 473 mL Bottle 48433-200-16 473 mL (4 mEq/mL) Strong Iodine Solution, U.S.P. (Lugol’s Solution) N/A 48433-230-15 14 mL 14 mL Glass Bottle with Dropper (Rx Only)
All products are manufactured in the U.S. by firms registered with and inspected by the U.S. Food and Drug Administration (FDA).
Please send completed product stocking request form to your wholesaler contact AND also send a copy to Safecor Health (email to: [email protected] or fax to 866-798-5333)
Safecor Health www.safecorhealth.com 800-447-1006 [email protected]