Refill Rx Request
LTC SERVICE TYPE
Select Service Type
LTC at Home
LTC Facilities
PATIENT INFORMATION
First Name*
Last Name*
Date of Birth*
Phone*
Enter Rx Numbers
Rx Number*
Add
Rx Number
Shipping Details
Street address
*
Street address *
Apartment, suite, etc.
Apartment, suite, etc.
City
*
City *
State
*
State *
Zip
*
Zip *
Shipping Method
1 day shipping
2 days shipping
I would like to receive offers and promotions from TIB Pharmacy.
By completing this form, I acknowledge all of the information provided above is correct and I authorize TIB Pharmacy to process my refill and charge my credit card.
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Most refill orders are processed within 7 business days of the request.
Submit