Scan_179.pdf

VA FORM 10-2321 Narcotic Dispensing/Receiving Report for MASTER VAULT-MAIN PHARMACY Page: 1

05/07/2026

DATE DATE

DISP # DISPENSED QTY DRUG ORD ORDERED BY

Destruction # 24317

05/07/2026 (~) Witnessed by:

(Full Name)

5MG/ACETANINOpHEN

Witnessed by:•

(Full Name)

COMMENTS: broken tab mfg:Mallinckrodt lotOl23K2S300 ndcO4OG-0l23-0l jt~

~AA~

HOLD # DRUG

DESTROYED CS DRUGS REPORT for DEA FORM 41 Dispensing Site: MASTER VAULT-MAIN PHARMACY Printed: JUN 4,2026

# OF

PAGE: 1

CONT QTY UNIT

u~ L~4~C-~ ~

24317 24318 243194” 24320 4’ 24321 4~ 24322 4~ 24323 24324 —

24325 24326 24327 24328 4, 24329 ~ 24330 243314;

24332 1 24333 243 34 2433 54~.

2433 6,~ 24337 24338 24339~4 24340 4, 24341 4, I

4r ~ 4_%L;.:-\

Date:

Destroyed By:

A

Witnessed By:

Witnessed By: •.. ~_-

HYDROCODONE 5MG/ACETRMINOPHEN 325MG TAB

HYDROCODONE 10/ACETABINOPHEN 325MG TAB

METHYLPHENIDATE 10MG TAB UD

OXYC000NE CONC 2OMG/ML SOLN 1ML UD

BUPRENORPHINE 2MG TAB,SUBLINGUAL

REMIFENTANIL HCL 2MG/VIL INJ

REMIFENTANIL HCL 1MG/VIL INJ

XNF CLONAZEPAM (BRAND) 1MG TAB

TEMAZEPAM 15MG CAP

OXYCODONE CONCENTRATED 2OMG/ML SOLN

METHADONE HCL 2MG/ML SOL ORAL, 5ML UD

METHADONE HCL 2MG/ML SOL,ORAL,25ML UD

TRAMADOL HCL 50MG TAB * CS *

HYDROCODONE 10/ACETAMIMOPHEN 325MG TAB

HYDROCODONE 10/ACETAMINOPHEN 325MG TAB

BUPRENORPHINE 2MG/NALOXONE 0.5MG SL TAB

BUPRENORPHINE 8MG/NALOXONE 2MG SL TAB

XNF LORAZEPAM 2MG/ML ORAL CONC UD,1ML

CHLORDIAZEPOXIDE 25MG CAP UD

LORAZEPAM INJ 2MG/ML,1ML

ZOLPIDEM TARTRATE 6.25MG SA TAB DO

LORAZEPAM INJ 2MG/ML,1ML

BUPRENORPHINE 2MG TAB,SUBLINGUAL

METHYLPHENIDATE 5MG TAB

MORPHINE S04 1MG/ML SOLN INJ PCA,3OML

1 1 tab 1 1 tab 1 10 tab 1 1 syr

1 1 TAB

1 1 VIAL

1 1 VIAL

1 81 TAB

1 40 CAP

1 3 ML

5 5 SYRINGE

6 6 SYRINGE

1 .5 tab

1 2 TAB

1 3 tab

2. 1 TAB

1 1 tab

1 5 syr

1 13 TAB

1 2 carpuject 1 ,2 tab

1 1 vial

1 2 TAB

1 1 tab 1 10 poe

END OF REPORT!!

Customer Info VA Central California

2615 E. Clinton Ave~ Fresno, CA 93703

Wholesaler None Provided

PkgVS~ze

•V~V•100VV

100 V V

10o~

1V

3V•

500 ml

500 ml 150

3OMIV

3cYMl

(559)225-6100

VDEA Number WholesalèrA~xt#

Class 2 Medication Inventory

NDC DEA Med Name Manufacturer Class f V

0406012501 2 ACETAM1NOPHEN-HYDROCODONE BITARTRAT TAB- 325 MG- SpecGX

0406012501 2 ACETAMINOPHEN-HYDROCODONE BITARTRAT TAB- 325 MG SpecGX

0406012501 2 ACETAMINOPHEN-HYDROCODONE BITARTRAT TAB- 325 MG- SpecGX

0406012301 2 ACETAM I NO P H EN-HYDROCODON E BITARTRAT TAB- 325 MG- SpecGX

0054355663 2 METHADONE HCLSOL- 10 MG/S ML Roxane

0054355663 2 METHADONE HCL SOl- 10 MG/5 ML Roxane

0406114401 2 METHYIPHENIDATE HYDROCHLOi~lDE TAB- 10 MG SpecGX

0406114201 2 METHYLPHENIDATE HYDROCHLORIDE TAB-S MG SpecGX

7632919121 2 Morphine 1r~g/rnL

0406855730 2 OXYCODONE HYDROCHLORIDE ORAL SOL- 100 MG/S ML (20 SpecGX

0406855730 2 OXYCODONE HYDROCHLORIDE ORAL-SOL- 100 MG/ S ML (20 SpecGX

6332372303 2 REMIFENTANIL HCL INJ- 1 MG Fresenius

6332372405 V 2 REMIEENThNIL HCL INJ 2MG .FrëseniusV

Count Destruction #

•~4~V~8

V24330

V 24331 24317

V 24327 V

24328 VV V VV~ V V V

V 24319. V S V

2434O~ V

24341J

V 24320 V V

V VV V V

V ~: V24~22 V V

0641600101.

04068b2003 0406800503 7288818230

.7~88818230~ ~.510~914i01 :6126961010 0409198503 01210770Q1 0406996101.

5140700701 6818077904

Full .:~. Partial Destru~tion # Packages Count .~

1 24338 24333

*0 :* ~ -.24~32*~ 0 .1 ~:243.21...

0. :..~::* .24339 p ~ 24.335~H:

~ ~ .24324.:

~ 24336 0 5 24334

4ó 243~.

0.5 24329 .2 24337

Customer info VA Central California . . . . Wholes~ier None Provided ~ . 2615 E. ClintohAve .

. Fresno, CA 93703 .

(559) 225-6100 Wholesaier Acct 4~

DEA Number

Controlled Medication Inventory

NDC ~ DEA

Class

Pkg Size

~0.

30~

.30.

1::

10O~

..-1.00

Med Name. . Manufácturei

4 ATIVAN SOL- 2 MG/ML West-Ward 3 BUPRENORPHINE AND NALOXONE SUBLINGUALTAB- SpecGX 3 Buprenorphine and Naloxone Sublingual Tabs 2mgfO 5 3 Buprenorphine Sublingual Tabs 2mg 3 Buprenorphine Sublingual Tabs 2mg 4 CHLORDIAZEPOXIDE HCL CAP- 25 MG Mylan Institutional 5 Clonazep~m 1mg Tab 4 Lorazepam injection 2mg/mL 4 LORAZEPAM SOL- 2 MG/ML Pharm Assoc Inc 4 Temazepam Cap 15mg 4 Tramadol Hydrochloride Tabs USP 50mg 4 ZolpidèmTattrate~6.25rng.Tab . -- . . . - . . .,.

Page lof 1

0~

DEA FORM-222 U.S. OFFICIAL ORDER FORMS - SCHEDULES I & II

DRUG ENFORCEMENT ADMINISTRATION

PURCHASER INFORMATION REGISTRATION INFORMATION SUPPLIER DEA NUMBER:# I I I I I I I I I

, — - I~_, • . ~ I I I I I

REGISTF ‘~9)N ~ PART 2: TO BE FILLED IN BY PURCHASER

REGISThR~D AS: ~1A C~ntr~1 CaIifprn~a~

5~SCHED1JLES: 2,2N,3,3N,4,5, BUSINESS NAME

ORDER FORM NUMBEF 2615 F. Clinton Ave.

DATE ISSUED STREET ADDRESS

~ ORDERFORM ~e~nc,CA937~

CITY, STATE, ~ZIP CODE

PART 1: TO BE FILLED IN BY PURCHASER PART 3: ALTERNATE SUPPLIER IDENTIFICATION - to be filled in by first supplier

~ PART 5~ (name in part 2) if order is endorsed to another supplier to fill.

~ TOBE ALTERNATEDEA#

~~ FILLED IN BY

~J PIJRCKASER Signature- byirst supplier .. ... 6/4/2026

Signature of Requesting Official ~i~’ust be authorized to sign order form) Date

— OFFICIAL AuTHORIZED TO EXECUTE ON BEHALF OF SUPPLIER DATE rr~tvi NO. OF PACKAGE NAME OF ITEM NUMBER] DATE PART 4: TO BE FILLED IN BY SUPPLIER NUMBER DATEPACKAGES SIZE RECD RECD NATIONAL DRUG CODE SHIPPED SHIPPED

1. i/10L. .~ A~TAMt~PHEN~ll~QQQNF BITARtRAT TAR- 325 MG-iOt~ I____ ~ O~ 0 G~- 0- 1~ ~ ~ ~‘-4~ 2t~ 1 i,L1OIL_ ACErAMINOP~DRn€ODQ~ITARTRATTAB-325 MG-1ê~- 0 .4_ ..Q. ~ 2.. ~ 2. I t~

-._ /100..2.~TAB-~ o~ a- 4 0 &- 0~ ~ 2 £ c~ i~ ~— ,~-. /100~ ~ ~ s~oizs~~ :~- - ... .- .~ ~ ~ ~- Co ‘4’ Z(~

..._1__ 5L~iQ0_~ ..~ G~ 0 5 4~- 3 5- 5 & 6. 3: 1

~ L_ Q~0Q. M~HYLPHENIQA~E~1V~CKLORIDE TA~ 1OM~ ~ -Q~ ~ ~ ~ ~_ ‘ ~. ~ 24’

,.. I1OQ . MTH?LP~IE~IpA1E ~WD~CKLORIDE TAB~ SM~~ Q~ Q~ 4 0 ~ 1 1 4- 2 (~ t 1: (p . (~ ~9’

4- ~0Q/3O - - ,,,. / 0-- ‘6 3 -~ 9 1 -~ 2 1 ao 1 ~/30 OXYCODONE HY~~~LO~IDE ORAL SOL- 100 MGI 5 ML (20’M~R~)-- I_____ L ..4_ iL L ~ ~ . i-f. ~

5 ML (2O-~f~ S.

~ ./1 REMIFEN.TAN~L F~1~-1MG ~ -1- 2~ ~ I (~ •~‘

~ 1 .— -~•.•- .-~.• ~ a i

~, S -: - ... S.-

~ +~LAST LINE COMPLETED (MUST BE 20 OR LESS)