New Customer Sign Up

Pharmacy Name: *Contact Name: *Phone: *Fax: *E-Mail: *Mailing Address for Checks: *City, State, Zipcode: *Pick Up Address: *City, State, Zipcode: *DEA License Number: *Expiration Date for DEA: *State License Number: *Expiration Date for State License: *Hours of Operation: Primary Wholesaler Name: *City, State, Zipcode: *Account Number: Secondary Wholesaler Name: *City, State, Zipcode: *Account Number: Date Opened: Rep Name: *Carrier: FedEx UPS *Driver Needed? Yes No Rate: *Batch: Yes No Frequency of Returns: Comments: