Account Information

Buyer First Name :
Email:
Buyer Last Name:
Phone Number:

Pharmacy Information

Business/Pharmacy Name:
Doing Business As:

Pharmacy Documentation

DEA Number:
State License Number:
Type of pharmacy:
Pharmacy’s Phone Number:
Pharmacy Email:
Years in business:
DEA File: View
State License File: View
Fax Number:
National Provider Number (NPI#):
Tax ID

Pharmacy shipping information

Street Address:
City:
State:
Zip Code:

Pharmacy billing information

Street Address:
City:
State:
Zip Code:

Trade reference

Primary Wholesaler:
Secondary Wholesaler:
Account #1:
Account #2:

How did you hear about us?

How did you hear about us: