Special Purchase Store - Pharmacy
Store Name and WIC Retail Number:
Store Address:
Phone and Fax Number:
E-Mail Address:
Please give your shelf price for these special formulas and medical formulas. Do not include sale prices. Give prices for only the sizes indicated. If you do not stock a listed item or do not stock an item in the size indicated, leave blank.
Formulas / Formulas
Pregestimil LIPIL – 16 oz powder can / $ / Neocate Junior – 14 oz powder can / $
Similac Expert Care Alimentum – 16 oz / Nutren Junior – 8.45 oz RTU can / $
powder can / $ / PediaSure – 8 oz RTU 6 pack / $
EnfaCare – 12.8 oz powder can / $ / PediaSure with fiber – 8 oz RTU 6 pack / $
Elecare Infant with DHA & ARA – 14.1 oz / Peptamen Jr. – 8.45 oz RTU can / $
powder can / $ / Similac PM 60/40 – 14.1 oz powder can / $
Neocate with DHA & ARA – 14 oz / Boost Kids Essentials with Probiotic straw –
powder can / $ / 8.25 oz RTU – 4 pack / $
Similac Expert Care NeoSure – 13.1 oz / $ / Boost Kids Essentials 1.5 – 8 oz RTU box / $
powder can / $ / PediaSure Peptide 1.0 Calorie – 8 oz RTU
Nutramigen with Enflora LGG - 12.6 oz / bottle / $
powder can / $
Elecare Junior Vanilla – 14.1 oz powder can / $
Elecare Junior Unflavored – 14.1 oz
powder can / $
Nutramigen AA – 14.1 oz power can / $
How many days notice do you need to get in a specialized formula? ______days
I hereby certify that the information recorded is correct to the best of my knowledge.
Please circle those days your truck comes in with shipments: S M T W Th F S
PLEASE COMPLETE & RETURN
/ Signature / DateBY NOVEMBER 26, 2012
THANK YOU!
Print Name