New Pharmacy Account
Business Name & DBA (If Different)
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Shipping Address
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City
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State
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Zip
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Billing Address
City
State
Zip
Phone
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Fax
Email Address
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Cell Phone Number
Pharmacy License Number (State Board Of Pharmacy)
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Pharmacy License Expiration Date
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DEA License Number
DEA License Expiration Date
Business Hours
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Number Of Daily Scripts
Tax ID #
Should we charge tax?
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Yes
No
Pharmacy Type
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Retail
Closed Door
Compounding
Other
How Long Has The Pharmacy Been In Business?
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Do You Own Any Other Pharmacies? If Yes, Provide Name(s)
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Date Business Established
Sales Tax Exemption Number
Anticipated Monthly Purchases (USD):
Type Of Business:
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Sole Ownership
Partnership
Corporation
TRADE VENDOR REFERENCES: U.S. companies with whom you have established business relations:
1. Company
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Telephone
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Address
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Email
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Contact
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Title
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Date Business Relations Established
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2. Company
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Telephone
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Address
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Email
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Contact
*
Title
*
Date Business Relations Established
*
3. Company
Telephone
Address
Email
Contact
Title
Date Business Relations Established
I hereby authorize Alpine Health to contact the above listed references.
Completed By
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Title
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Date
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Submit
