Web Refill Request

Fill out the form below to have your
prescription ready for pick up at:

      Teplow Drugs
      404 East Main Street
      Barstow, CA 92311
      (760) 256-2726

Pharmacy Hours:

* First Name:

* Callback Number:

* Last Name:

Pick Up Date:

Date of Birth:

(mm/dd/yyyy)

Pick Up Time:

* Rx Number(s):

Use commas to separate if entering more than one prescription.

E-mail Address:

(if you want e-mail confirmation of this refill)

* is a required field.

ONLINE PRESCRIPTION REFILL