Account Application
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?
  • Yes
  • NO
  •    (if no, give tax ID number and attach copy of sales tax certificated)

Tax ID:

*

 

DEA Number:

*

 

DEA Exp Date:

*

 

Ownership:

  • Sole Proptietor
  • Corporation
  • Partnership
  • LLC

DUNS Number:

Year in Business:

*

 
Purchasing Contact

Account Payable Manager:

*
 

Buyer Name:

*
 

Payment Options:

 

  • 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:

Provide Documents

State Board :


DEA License:


Sales Tax Exempt :

Please upload document or fax to (734) 729 - 7288
Miscellaneous documents :

Miscellenous documents 1:


Miscellenous documents 2:


Miscellenous documents 3: