FDA DRUG LISTING FORM

Labeler (Must be same as in the NDC Labeler code)
     
     
* Labeler Business Type:
Own-Label Manufacturer [ ? ] Private Label Distributor (PLD) [ ? ] Contract Manufacturer [ ? ] API Manufacturer [ ? ]
Packer Labeler Relabeler Repacker Transfiller
Manufacturer (Name of Establishment manufacturing the Drug)
     
Drug Product Information
     
Package type (carton, tube, box, bottle etc..)
     
     
DEA Schedule (if applicable)                     CI                CII                 CIII                 CIV                 CV
Characteristics
     
     
     
 
     
     
Active Ingredients       Active Ingredient
(eg. Avobenzone )		   Strength
(eg.200mg in 1 ML)		   UNII (if known)
(Unique Ingredient Identifier)
Please list All
Active
Ingredients,
Strength and
UNII (if known)		   1.      
  2.      
  3.      
    4.      
(please use
additional form if
you have more
than 8 Active
ingredients)		   5.      
  6.      
  7.      
    8.      
 
Inactive Ingredients       Inactive Ingredient
(eg. Water )		   Strength
(Optional)		   UNII (if known)
(Unique Ingredient Identifier)
Please list All
Inactive
Ingredients,
and UNII (if
known)
Strength is
optional		   1.      
  2.      
  3.      
    4.      
(please use
additional form
if you have
more Inactive
Ingredients)

   5.      
  6.      
  7.      
    8.      
    9.      
    10.      
    11.      
    12.      
    13.      
    14.      
    15.      
    16.      
    17.      
    18.      
    19.      
    20.      
    21.      
    22.      
    23.      
    24.      
Other Informations (if any)
 

 

Submitter Name        Job Title        Submitter E-mail