Pharma Logistics: New Customer Signup

Questions?
Call us toll-free at
888-729-7427

Facility Information
Name of Pharmacy:	*
	(as appears on DEA Certificate)
Address:	*
City:	* State: * Zip Code: *
Telephone:	*
Fax:	*
DEA #:	* DEA Expiration: *

Purchasing Group:
Cost Code:	(i.e. BRUSHCLEAN)

Pharmacy Contact Person:	*
Title	*
Email Address:	*

Pharmacy Contact Person:	*
Title	*
Email Address:

Accounts Payable/Statement Information
Contact:
Address:
City:	State: Zip Code:
Telephone:
Fax:
Email Address:

Wholesaler Information
Name of Wholesaler:	*
Wholesale Acct. #:	*
Contact Person:
Contact Title:
Address:	*
City:	* State: * Zip Code: *
Telephone:	*
Fax:	*

Direct Accounts
Name of Manufacturer:	Account #:
Name of Manufacturer:	Account #:
Name of Manufacturer:	Account #:
Name of Manufacturer:	Account #:

How did you hear about us?
Referral: