Pharmacy Account Application

Complete the form below to apply for ordering access. Approval typically takes up to 5 business days.

1. Contact Information

Edit

Pharmacy Name *

Pharmacist-in-Charge Name *

Contact Email *

Purchasing Contact Phone *

2. Regulatory Identifiers

Edit

NPI Number * 10-digit number (e.g., 1234567890)

GLN (Global Location Number) 13-digit GS1 identification key used for the DSCSA (Drug Supply Chain Security Act)

SGLN (Serialized Global Location Number) GLN + an extension

State License Number *

State License Expiration Date *

Federal Tax ID / EIN * Format: 12-3456789

3. Addresses

Edit

Shipping Address

Street Address Line 1 *

Street Address Line 2

City *

State / Province *

ZIP Code *

Billing Address

Same as Shipping Address

Street Address Line 1 *

Street Address Line 2

City *

State / Province *

ZIP Code *

4. Document Uploads

Edit

State Pharmacy License

Upload File or drop files here

PDF, JPG, PNG, up to 10MB

Resale Certificate Download templates

Upload File or drop files here

PDF, JPG, PNG, up to 10MB

Form W-9

Upload File or drop files here

PDF, JPG, PNG, up to 10MB

Credit Application Download templates

Upload File or drop files here

PDF, JPG, PNG, up to 10MB

Terms and Conditions Download

Upload File or drop files here

PDF, JPG, PNG, up to 10MB

I have read, signed, and agree to Perfero’s Terms and Conditions.