NEW USER REGISTRATION

[CUSTOM.MESSAGE]

If your Hospital has an account with us, please reach out to your sales representative for account details or email orders@staqpharma.com. This form is for New Customers.

Status Message:
[STATUS]

Username:

Email Address:

First Name:

Last Name:

New Customer Information

Hospital/Facility Name:

Group Purchasing Organization (GPO): [GPO.DROPDOWN]

Integrated Delivery Network Name (IDN):

Ship To Address

Shipping Address 1:

Shipping Address 2:

City:

State: [SHIPSTATE]

Zip Code:

Pharmacy Phone Number:

Licensing Information - please send pdf of all licenses

Pharmacy License#:

Pharmacy License Expire:

DEA License#:

DEA License Expire:

Authorize DEA CSOS Signer:

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

Paper E222 form to be Emailed to Staq Pharma 14135 E 42nd Avenue Denver Co 80239

Electronic CSOS: [CSOSFLAG]

Billing Information

Attention To:

Billing Address 1:

Billing Address 2:

Billing Address 3:

City:

State: [STATE]

Zip Code:

Accounts Payable Contact (Billing)
Any AP questions Email : ap@staqpharma.com

Accounts Payable Contact (Only):

Phone:

Email:

Invoice Receipt Method: [INVMETH]

Contacts

Director of Pharmacy:

Email:

Phone Number:

Pharmacy Buyer

Contact:

Phone:

Email:

Recall Coordinator (In the event of a Recall)

Contact:

Phone:

Email:

Upload Documents With Your Registration

View Uploaded Documents

Please upload your files before you submit the registration:

Web Login to Copy Profile from :

NEW USER REGISTRATION

New Customer Information

Ship To Address

Licensing Information - please send pdf of all licenses

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

Billing Information

Accounts Payable Contact (Billing) Any AP questions Email : ap@staqpharma.com

Contacts

Pharmacy Buyer

Recall Coordinator (In the event of a Recall)

Upload Documents With Your Registration

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

Accounts Payable Contact (Billing)
Any AP questions Email : ap@staqpharma.com