Completed Internet Form - NOT FOR SUBMISSION DEA/Control Number - FS5672363 Submission Date: 01-21-2019 APPLICATION FOR REGISTRATION UNDER CONTROLLED SUBSTANCES ACT OF 1970 Form DEA 224A - Completed Internet Receipt. NOT FOR SUBMISSION NAME: APPLICANT OR BUSINESS (LAST) ,SHULIAK (First, MI) KARYNA _ TAX IDENTIFYING NUMBER AND/OR SOCIAL SECURITY NUMBER XXX-XX-4619 PROPOSED BUSINESS ADDRESS. (WHEN ENTERING AM. BOX, YOU ARE REVAREO To ENTER A STREET ADDRESS) 6100 RED HOOK QTRS STE B-3 CITY ST THOMAS APPLICANTS BUSINESS PHONE NUMBER POC NAME REGISTRATION CLASSIFICATION STATE ZIP CODE VI 00802 - 1348 POC CELL PHONE NUMBER POC EMAIL 2. INDICATE 1. HERE IF YOU BUSINESS PRACTITIONER REQUIRE ACTIVITY: ORDER FORM BOOKS. 3. Drug Schedules. (Fill in all circles that apply) ,/ Schedule II ,/ Schedule II ,,, Schedule III i Schedule III V' Schedule IV ,/ Schedule V Narcotic Non Narcotic Narcotic Non Narcotic Practitioner Details National Provider ID 1063886083 * Degree IIIIIIIMIMIIIIIIIIIIIIIIIII * Birthdate MEM NM Illia * Graduation Year IIIIIMI * Professional School COLUMBIA UNIVERSITY COLLEGE OF D 4. All Applicants must answer the following: Are you currently authorized to prescribe, distribute, dispense, conduct research, or otherwise handle the controlled substances in the schedules for which you are applying under the laws of the state or jurisdiction in which you are operating or propose to operate? State License No. , . State: VI Expire Date: 09-30-2020 State Controlled Substance Lic. No. Expire Date: -- 1. Has the applicant ever been convicted of a crime in 4. If the applicant is a corporation (other than a connection with controlled substance(s) under state or corporation whose stock is owned and traded by federal law, or been excluded or directed to be excluded N the public), association, partnership, or pharmacy, from participation in a medicare or state health care has any officer, partner