Welcome to Devine's Pharmacy

	*Your Full Service Pharmacy... And So Much More!*	1949 Oak Tree Road, Edison, NJ 08820 Phone: 732-549-7117 • Fax: 732-549-7080 Email: info@devinespharmacy.com Monday to Friday 9:00 am to 9:00 pm Saturday 9:00 am to 6:00 pm Sunday & Holidays 9:00 am to 2:00 pm

Customer Information
*Name:
*Address Line1:
Address Line2:
*Town:
*State:
*Zip Code:
Deliver to if different than address above
Name:
Address Line1:
Address Line2:
Town:
State:
Zip Code:
Prescription Items
Prescription number(s) or name(s) of Medication:
Doctor Name:
Non-Prescription Items
Description of Items:
Delivery Options
$1.00 Delivery Charge
*Delivery Date:	*(For PICK-UP Orders Indicate* *"Pickup"* *and MM/DD/YY)*	MM/DD/YYYY
*Delivery Time:	(For PICK-UP Orders Please Indicate *"Pickup"* and Time)	12:30pm, 4pm
*Phone:
*E-Mail:
Important: Enter a valid e-mail address. Receipts will be sent to this address.

Payment Options
*payment options:	Cash Check Devine's Account acc# Credit Card	choose the suitable option
Name on Card:		Same name as on your card
Card Number:		No dashes or spaces please
Expiration Month:		From your card
Expiration Year:		From your card
Card Type:
CVV2:		Card Security Code
Note: * is a required field	Will there be anything else?