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Pharmacy Information

Pharmacy Name:

Doing Business As:

Phone Number:

Fax Number:

Email:

Shipping Address:

State:

City:

Zip Code:

Check if the billing address is same as shipping address

Billing Address:

State:

City:

Zip Code:

Should we charge sales tax?

Yes No (if no, give tax ID number and attach copy of sales tax certificate)

Tax ID:

DEA Number:

DEA Exp Date:

Ownership:

Sole Proprietor Corporation Partnership LLC

DUNS Number:

Year in Business:

Purchasing Contact

Account Payable Manager:

Buyer Name:

Have you ever filed Bankruptcy:

Yes No

Bank Reference

Name of the Bank:

Type of Account:

Banker :

Phone:

Account Number:

Provide Three References

1st Company Ref :

Phone:

2nd Company Ref :

Phone:

3rd Company Ref :

Phone:

How did you hear about us?

Provide Documents

State Board:

DEA license:

Sales Tax Exempt:

Registration

Registration

Pharmacy Information

Purchasing Contact

Bank Reference

Provide Three References

Provide Documents

Miscellaneous Documents