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New User Registration
Username or Email Address:
Account Code or Customer Number:
If you have an existing account with us, Please enter it and we will associate your login with your account. (Leave Blank if you do not have one)
First Name:
Last Name:
New Customer Information
Hospital Name:
Group Purchasing Organization (GPO):
Integrated Delivery Network Name (IDN):
Ship To Address
Shipping Address 1:
Shipping Address 2:
City:
State:
ALABAMA
ALASKA
ALBERTA
ARIZONA
ARKANSAS
ARMED FORCES AMERICAS
ARMED FORCES CANADA
ARMED FORCES PACIFIC
CALIFORNIA
CANAL ZONE
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLOMBIA
FLORIDA
FOREIGN
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UNKNOWN
UNKNOWN
UNKNOWN
UTAH
VANCOUVER
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
No selection
Zip Code:
Attention Location (Suite/Room/Person)
Please do not put Pharmacy:
Pharmacy Phone Number:
Additional Notes:
Licensing Information -
please send pdf of all licenses
Pharmacy License#:
Pharmacy License Expire:
DEA License#:
DEA License Expire:
CSOS DEA Signing Authority:
Controlled substance order method
CSOS will not only increase compliance at your hospital, but will also reduce paperwork and decrease time taken for order fulfillment
Electronic CSOS:
No selection
Yes
No
Billing Information
Attention To:
Billing Address 1:
Billing Address 2:
Billing Address 3:
City:
State:
ALABAMA
ALASKA
ALBERTA
ARIZONA
ARKANSAS
ARMED FORCES AMERICAS
ARMED FORCES CANADA
ARMED FORCES PACIFIC
CALIFORNIA
CANAL ZONE
COLORADO
CONNECTICUT
DELAWARE
DISTRICT OF COLOMBIA
FLORIDA
FOREIGN
GEORGIA
GUAM
HAWAII
IDAHO
ILLINOIS
INDIANA
IOWA
KANSAS
KENTUCKY
LOUISIANA
MAINE
MARYLAND
MASSACHUSETTS
MICHIGAN
MINNESOTA
MISSISSIPPI
MISSOURI
MONTANA
NEBRASKA
NEVADA
NEW HAMPSHIRE
NEW JERSEY
NEW MEXICO
NEW YORK
NORTH CAROLINA
NORTH DAKOTA
OHIO
OKLAHOMA
OREGON
PENNSYLVANIA
PUERTO RICO
RHODE ISLAND
SOUTH CAROLINA
SOUTH DAKOTA
TENNESSEE
TEXAS
UNKNOWN
UNKNOWN
UNKNOWN
UTAH
VANCOUVER
VERMONT
VIRGIN ISLANDS
VIRGINIA
WASHINGTON
WEST VIRGINIA
WISCONSIN
WYOMING
No selection
Zip Code:
Pharmacy Invoice Email :
Accounts Payable Contact (Billing)
Contact:
Phone:
Fax :
Email:
Invoice Receipt Method:
No selection
Printed paper
EMail
Special Set up Instruction if any:
Contacts
Director of Pharmacy:
Order Contact:
Business Contact (Vendor Accounts)
Contact:
Phone:
Email:
Recall Coordinator (In the event of a Recall)
Contact:
Phone:
Email:
Upload Documents With Your Registration
Please upload your files before you submit the registration:
Web Login to Copy Profile from :
Once your new login is created we will email you a new password. Don't worry, you can change it once you login. Please review the messages below after you click register.
Status Message:
Please Enter your Information Above and Click Register New User to create your new user account.