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Drug Establishment Registration / NDC Code Request Form
Type of Submission
Select one or both
*
Obligatoire
Drug Establishment Registration
Labeler Code Request
Establishment
Establishment Name
City
Country
FDA Registration Number
Street Address
State
Postal Code
DUNS Number
Establishment Contact
Name of Contact Person
Street Address
State
Postal Code
Job Title
City
Country
Phone Number
Email
Type of Operation
Type(s) of Operation
*
Obligatoire
Manufacturer
Contract Manufacturer
Contract Sterilizer
Developer
Initial Importer
Foreign Exporter
Relabeler
Labeler
Other (Explain)
Drug Status
Select below if applicable
*
Obligatoire
OTC
Prescription
API
Veterinary
Homeopathic
US Importer / Distributor
US Importer / Distributor Name
DUNS Number
Email
FDA Registration Number
Address
Phone Number
Submitter Name
Submitter Job Title
Submitter Email
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