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:


Accountant:

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: