Step1: Store Information
Step1: Buyer Information
Business Legal Name *
{{ generalValidationMsg }}
{{ getValidationMsg("legal_company_name") }}
Business Trade Name*
{{ generalValidationMsg }}
{{ getValidationMsg("legal_trade_name") }}
Website
{{ getValidationMsg("website") }}
Legal Address (Must match DEA/HIN Address)
Street *
{{ generalValidationMsg }}
{{ getValidationMsg("legal_address") }}
City *
{{ cityValidationMsg }}
{{ getValidationMsg("legal_city") }}
State *
Select One
{{ state.state_name }}
{{ selectBoxValidationMsg }}
Zip *
{{ zipValidationMsg }}
Telephone *
{{ phnValidationMsg }}
Fax
{{ phnValidationMsg }}
Notice:
We routinely send notifications, such as price lists, special offers, and other advertisements to our network pharmacies as a service to the pharmacies. By providing your facsimile number, you are requesting and agree to receive these advertisements from {{sitename}} via facsimile.
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