New Customer Setup Form Form Submission is restrictedForm is successfully submitted. Thank you!Shipping InfoLegal Name*DBA Name (if any)Shipping Address*City*State*AlabamaAlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZip*Billing InfoSame as Shipping AddressBilling AddressCityStateAlabamaAlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingZipOther InfoBusiness Phone*Email*FaxOwner's Name*Account payable manager*PIC Name*PaymentPayment OptionsACH draft (Automatic draft 10th of each month)Check (Net 30)Credit card (Point of sale)Have you ever applied for bankruptcy?*YesNoRecurring Payment Authorization Form 082021Business InfoNPI #*Years in businessGLIN #What type of pharmacy are you ?Retail PharmacyDr./Physician officeClinicHospitalLong Term Care FacilityChain PharmacyState Pharmacy License* Upload% Completed0DEA License* Upload% Completed0Additional Documents Upload% Completed0State BOP lic. #*DEA License #Trade ReferencePrimary Wholesaler*Account #1*Secondary Wholesaler*Account #2*Enter the name of your Republic Pharmaceuticals representative?*If you don't have a representative, please enter NA. Submit
