SUBMIT ORDER

Pharmacy Stock Order Form – Kenya

Pharmacy Stock Order Form

Supplier Name

PPB Wholesale License No.

Address / Contact

Pharmacy / Facility Name *

PPB Premises Registration No. *

Physical Address

County

Annual Practice License No.

Superintendent Pharmacist / Technologist *

Contact Number *

Email Address

Order Number (Supplier)

Order Date

Requested Delivery Date

Source of Funds

Only KEML/KEMSL or registered products. Attach permits for controlled drugs if applicable.

#	Product Code	Generic Name & Strength	Dosage Form	Pack Size	Qty Ordered	Unit Price (KES)	Total (KES)
1

Grand Total (KES): 0.00