Los Altos Pharmacy and Compounding Center

Prescription Refill

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First Name*:
Last Name*:
Phone Number*:
Your e-Mail*:
Mailing Address:
City:
State:
Zip Code:
First Refill Number*:
Second Refill Number:
Third Refill Number:
Fourth Refill Number:
Fifth Refill Number:
Comments or Special Requests:
Pickup or Delivery?
If Delivery, please leave your credit card information in the comments section above (if we don't already have it on file), or call us with special billing instructions.

Los Altos Pharmacy
255 Second Street
Los Altos, CA 94022

• 650-948-1212 phone
• 650-949-2269 fax
• pharmacist@losaltospharmacy.com