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["附件1"]
["零售药店医保定点申请表"]
["零售药店名称"]
["零售药店地址"]
["法定代表人姓名",{"$nulls":3},"法定代表人身份证号码"]
["法定代表人电话"]
["经营方式",null,"□ 连锁企业直营门店"]
[null,null,"□ 加盟店"]
[null,null,"□ 单体店"]
["连锁总部名称"]
["单位经办人",{"$nulls":4},"联系电话"]
["药店用房性质（自有/租赁）",{"$nulls":4},"药店用房租赁合同剩余有效期限"]
["药品经营许可证号",{"$nulls":4},"药品经营许可证取得时间"]
["统一社会信用代码",{"$nulls":4},"营业执照取得时间"]
["工作人员","注册执业药师",null,"药师",null,"从业药师",null,"其他工作人员"]
["总数","药师","中药师","药师","中药师","药师","中药师"]
[]
["申请单位意见","       本单位自愿承担医疗保障服务，承诺提供的所有材料真实、完整、有效。如承诺内容和材料与事实不符，愿承担由此造成的一切后果。\n\n\n                                                                           法定代表人签字：\n\n\n                                                                                单位盖章：\n                                                                               年   月   日"]

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