Customer Setup

Legal Name *

DBA Name (if any)

Shipping Address *

City *

State *

Zip *

Same as Shipping Address

Billing Address

City

State

Zip

Business Phone *

Email *

Fax

Owner's Name *

Accounts payable manager *

PIC Name *

Payment Options

ACH draft (Automatic draft 10th of each month) Check (Net 30) Credit card (Point of sale)

Have you ever applied for bankruptcy? *

Yes No

NPI # *

Years in business

DUNS

State Pharmacy License*

DEA License *

Additional Documents

Payment Information Form * Download form here.

Primary Wholesaler *

Account # 1 *

Secondary Wholesaler *

Account # 2 *

New Customer Setup Form