To request a refill of a medication or supplies, please complete the form below.  All requests submitted from
9am-5pm Monday thru Friday will be worked the same day.  Do note that the date on which the supplies are
delivered is subject to availability.  

To learn what our process is for filling orders, please click on Our Process.
Refill Requests
NOTE: These requests are only checked Mon-Fri 9am-5pm
Patient Name
Requested
Delivery Date:
Patient DOB
Patient
Address
Patient Phone
Number
Refill Prescription
Numbers
If the prescription number is not
available, please provide the drug
name.  Do NOT use this form for
new prescriptions.
Your Name & Phone Number
This section must be completed in
case there are issues with the request.
Notes/ Special Requests
NORTHERN PHARMACY
International Services
Español
6701 Harford Rd Baltimore MD 21234
Tel: 443-909-7884 (Sarah) or 410-254-2326 (Zainab)
Fax: 443-909-7881
Request a Refill