Hospital Pharmacy
/ Surgery Center Information

Please fill out the form below

Client Info
Hospital Pharmacy / Surgery Center Info
Director of Pharmacy
Pharmacy Buyer 1
Pharmacy Buyer 2
How does your hospital order controlled substances?
Licensing
Please attach a copy of the facility State Pharmacy License and DEA License.
Upload State License
Upload DEA License
Shipping Info
Facility
Attention
Address
Billing Info
Billing Contact
Billing Address
Product Selection
In order for Wells Pharma to reliably provide you with the products that you need, we request your estimated Monthly Usage for products that you will be ordering. This is NOT a commitment from you to buy any quantities from Wells Pharma.
Will you be setting up a recurring order?
How does your facility order controlled substances
1) Item / Product Description
2) Item / Product Description
3) Item / Product Description
4) Item / Product Description
5) Item / Product Description
6) Item / Product Description
7) Item / Product Description
8) Item / Product Description
9) Item / Product Description
10) Item / Product Description

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