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["供货单位（批发、生产）冷链药品质量保证能力确认表      "]
[{"$nulls":3},"日期"]
["企业名称（盖章）"]
["注册地址"]
["经营方式",null,"药品经营许可证号"]
["经营范围"]
["质量负责人",null,"联系电话"]
["业务联系人",null,"联系电话"]
["冷链设施、设备情况"]
["阴凉库面积（㎡）",null,"温度记录仪型号及数量"]
["冷库数量",null,"总容积（m³）"]
["验证结论"]
["冷藏车数量",null,"总容积（m³）"]
["验证结论"]
["保温箱型号及数量",null,"总容积（L）"]
["验证结论"]
["包装材料情况"]
["验证结论"]
["冷藏药品运输方式","冷藏车（  ）   保温箱（  ）  包装材料（  ）"]
["是否委托配送",null,"委托配送单位"]
["冷链管理制度有无",null,"备注"]
["质量承诺","1、所有资料真实有效，有据可查。如有虚假，愿意承担相应的法律责任。"]
[null,"2、配置必要的设施设备来保证冷藏药品储存、运输温度控制在规定的范围内。"]
[{"$nulls":3},"江苏省医药有限公司制表"]

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