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• Name*
  
• Contact Number *
  
• Address *
  
• Drug Licence No.*
  
• GST No.*
  
• Location*
  
• Owner's Name *
  
• Name Of Pharmacist *
  
• Number Of Staffs *
  
• Approximate Storage Value *
  
• How Many Diabetic Patients Do You Have? *
  
• How Many Cardiac Patients Do You Have? *
  
• Average Business Per Month*
  
• Number Of Stockists You Deal*
  

* Required Fields