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Pharmacy Details
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Personal Details:
Step 1 - 4
Full Name: *
Upload Profile Picture: *
Email: *
Country Code: *
Phone: *
Pharmacy Details:
Step 2 - 4
Shop name: *
Address :*
Landmark :*
City: *
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Kochi
Thrissur
Ayyanthole
Ambaloor
Chelakkara
Kunnamkulam
Guruvayur
Manalur
Wadakkanchery
Ollur
Nattika
Kaipamangalam
Irinjalakuda
Puthukkad
Chalakudy
Kodungallur
Zip Code: *
Image Upload:
Step 3 - 4
Trade License Number:*
Upload Trade License:*
Adhar no: *
Upload Adhar:*
Pan no: *
Upload Pan:*
GST Number:*
Upload GST:*
TIN Number:*
Upload TIN:*
Any Bill :*
Bank Pass book front page :*
Health Authority License Number:
Upload Health Authority License:
Drug licence number: *
Declation:
Step 4 - 4
I hereby declare that the information given in this application is true and correct to the best of my knowledge and belief. In case any information given in this application proves to be false or incorrect, I shall be responsible for the consequences. Also, I accept the
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