REQUEST FOR ROSTER FORM
Use this form to request that a roster of information be emailed you from the Maryland Board of Pharmacy. The Board of Pharmacy provides basic information to consumers regarding licensees, permit holders and registrants as part of the Public Information Act. The general roster information will include Names and Addresses in electronic format. 


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Today's Date *
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DD
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Name of Requestor *
Email Address *
Company Name *
Company Address *
Website Address
Telephone # *
Fax #
Roster Format *
Check all roster lists requested
Required
Specific Maryland Counties (if applicable)
Specific Zip Codes (if applicable)
Other Information Requested
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