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Personal Information
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Pharmacy Information
3
Address Information
4
Last Page

Account Information

Buyer First Name *
 Email *
Buyer Last Name *
Phone Number *

Password setup

It's important to use a secure password. You can create this with any combination of 8 or more mixed case letters, numbers or special characters (*? etc).

Password *
Verify Password *
Please enter your password

Pharmacy Information

Business/Pharmacy Name *
Doing Business As *

Pharmacy Documentation

Please upload a JPG, PNG, or PDF file to validate your DEA and State License. The limit size of the file is 40MB.

DEA Number *
State License Number *
DEA File *
Maximum file size: 40 MB
State License File *
Maximum file size: 40 MB
Type of pharmacy *
Pharmacy’s Phone Number
Fax Number
Pharmacy Email *
National Provider Number (NPI#) *
Years in business *
Tax ID

Pharmacy shipping information

Shipping Street Address *
Shipping City *
Shipping State *
Shipping Zip Code *
Street Address *
City *
State *
Zip Code *

Trade reference

Primary Wholesaler
Secondary Wholesaler 
Primary Wholesaler Account
Account #2

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