New Customer Application

OurPharma Account Manager*

Facility Information

Company Name*

Primary Pharmacy GPO Affiliation*

IDN*

Health System Affiliation*

Company Phone Number*

Fax Number

Company Email Address

Company Website

State Pharmacy License Number*

Enter N/A if you do not have a State Pharmacy License

DEA Number*

Enter N/A if you do not have a DEA number

Controlled Substance Registration Number (CDS, CSR, BNDD)*

Enter N/A if not in one of the following States: IA, IL, IN, LA, MD, MI, MS, MO, NJ, NM, NC, OK, OR, SC

Contact Information

Shipment Notification Email Group or Distribution List Address

It is recommended that a group inbox or distribution list be provided by your organization for shipment notifications.

Purchasing Agent/Buyer Phone Number/Ext*

Purchasing Agent/Buyer Email*

Director of Pharmacy Phone Number/Ext*

Director of Pharmacy Email*

Additional Pharmacy Contact 1 Number/Ext

Additional Pharmacy Contact 1 Email

Additional Pharmacy Contact 2 Number/Ext

Additional Pharmacy Contact 2 Email

Additional Pharmacy Contact 3 Number/Ext

Additional Pharmacy Contact 3 Email

Invoicing

Pharmacy Billing Contact Name and Title

Pharmacy Billing Contact Phone

Pharmacy Billing Contact Email*

Accounts Payable Contact Name and Title

Accounts Payable Contact Phone

Accounts Payable Contact Email*

Email Address For Invoice Receipt*

Additional Information Needed for Billing

All invoices will be sent via email unless otherwise specified here

Purchase Order Submission & Correspondence

Primary option: Online Portal via GraphiteRx e-commerce Platform. Secondary option: via mail that may incur order processing fees

FedEx Account Number

If Collect Freight Terms is selected, please enter your FedEx account number to be charged here.

File Upload

Please upload a copy of your DEA Registration, State Pharmacy License, and State Controlled Substance Registration, if applicable.

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 50 MB.

Copies of the these licenses are required for account registration. These can be uploaded now if available.

We have lowered our CADD MOQ's to better align with customer supply chain needs! You can check out our updated product catalog, inquire with your account manager, or contact [email protected] for more info.

Facility Information

Contact Information

Invoicing

Purchase Order Submission & Correspondence

File Upload