1. Pharmacy Location Information

 

 

2. Representative Information

 

 

3. Licensing Documentation

 

If you are having trouble uploading your state license file below, please try refreshing this page. If the problem persists, please complete registration and email your state license to [email protected] along with your pharmacy name and contact information.

 
 

 

 

4. Shipping Account Information

 

You only need to fill this out if you want orders shipped on your own shipping account.

 

5. Submit Information

 

Please type the following access code in the field below:

nospam