NEW CUSTOMER SIGNUP

Customers Qualify For The Following:
  • Reduced Compliance Pricing
  • Reduced All-Inclusive Pricing
  • Additional Features At No Additional Costs
  • Plus Much, Much More!

To obtain specific contract terms and conditions, details about individual statement of work, and /or pricing structures; contact your GPO or the Guaranteed Returns® contract administrator.

Please Tell Us Which Of The Following Pertains:

 
 BRANCH:
   
 
FACILITY/PHARMACY INFORMATION
 
DATE SUBMITTED:
FACILITY/PHARMACY NAME:  
ADDRESS:  
 
CITY & STATE:     ZIP CODE:
DEA REGISTRATION NO.:   EXPIRATION DATE:
BRANCH:           DSN NO.
POINT OF CONTACT:  
CONTACT PHONE NO.:   EXTENSION:
FAX NO.:
EMAIL ADDRESS:  
ALTERNATE CONTACT:
ALTERNATE PHONE NO.:     EXTENSION:
EMAIL ADDRESS:
 
PRIME VENDOR INFORMATION
 
Wholesaler (Prime Vendor)  
Wholesaler (Prime Vendor) City:          STATE:
 
CREDITING PRIME VENDOR ACCOUNT NUMBER: 
ALL CREDITS WILL BE POSTED TO THE ACCOUNT NUMBER LISTED ABOVE
 
Services of Interest:
 On-Site Support
Off Site
Reverse Link One
 
QUESTIONS, COMMENTS AND ADDITIONAL INFORMATION
 
  

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