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:
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:
Billing Information
Attention To:
Billing Address 1:
Billing Address 2:
Billing Address 3:
City:
State:
Zip Code:
Pharmacy Invoice Email :
Accounts Payable Contact (Billing)
Contact:
Phone:
Fax :
Email:
Invoice Receipt Method:
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.