Pharmacy Name: *
Doing Business As:
Phone Number: *
Fax Number: *
Email: *
Shipping Address: *
State: * AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming
City: *
Zip Code: *
Check if the billing address is same as shipping address
Billing Address: *
Should we charge sales tax?: *
YesNo
(if no, give tax ID number and attach copy of sales tax certificate)
Tax ID: *
DEA Number:
DEA Exp Date:
Ownership:
Sole ProprietorCorporationPartnershipLLC
DUNS Number:
Year in Business:
Account Payable Manager: *
Buyer Name: *
Have you ever filed Bankruptcy?
Name of the Bank: *
Type of Account: *
Banker
Phone
Account Number:
1st Company Ref: *
Phone: *
2nd Company Ref:
Phone:
3rd Company Ref:
GLN (Global Location Number) *
How did you hear about us?
State Board: *
DEA license: *
Sales Tax Exempt:
Miscellaneous Documents 1:
Miscellaneous Documents 2:
Miscellaneous Documents 3:
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