Pharmacy Information

    Pharmacy Name:

    Doing Business As:

    Phone Number:

    Fax Number:

    Email:

    Shipping Address:

    State:

    City:

    Zip Code:


    Billing Address:

    State:

    City:

    Zip Code:

    Should we charge sales tax?

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

    Tax ID:

    DEA Number:

    DEA Exp Date:

    Ownership:

    DUNS Number:

    Year in Business:

    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:

    Provide Documents

    State Board:

    DEA license:

    Sales Tax Exempt:

    Miscellaneous Documents

    Miscellaneous Documents 1:

    Miscellaneous Documents 2:

    Miscellaneous Documents 3: