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Store Details

Legal Name

Doing Business As

First Name

Last Name

Client Information

Contact Number

Best time to contact you

Email

City

State.

Zip Code

Total Monthly Volume

Monthly Generic Volume

Current Primary Wholesaler

Primary Wholeseller Account No

Store Phone

Store Fax

TAX ID / EIN

License Information

DEA No

Copy of DEA License

NCPDP #

NPI #

Resale Tax Certificate

Copy of Resale Tax Certificate

Pharmacy License

Copy of Pharmacy License

Control Substance License (If applicable)

Copy of Control Substance License

PIC License

Copy of PIC License

Review Form

5908 Breckenridge Parkway,
Tampa, FL 33610, USA

5908 Breckenridge Parkway,
Tampa, FL 33610, USA