Hospital Pharmacy
/ Surgery Center Information

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Client Info
Hospital Pharmacy / Surgery Center Info
Director of Pharmacy
Billing Contact
Pharmacy Buyer
How does your hospital order controlled substances?
Licensing
Upload State License
Upload DEA License
Shipping Info
Facility
Attention
Address
Deliver to Pharmacy Room
Billing Info
Same as Shipping?
Attention
Address
Product Selection
Will you be setting up a recurring order?
How does your facility order controlled substances
1) Item / Product Description
Ordering Frequency
Auto-Ship?
If 'Yes', what frequency
2) Item / Product Description
Ordering Frequency
Auto-Ship?
If 'Yes', what frequency
3) Item / Product Description
Ordering Frequency
Auto-Ship?
If 'Yes', what frequency
4) Item / Product Description
Ordering Frequency
Auto-Ship?
If 'Yes', what frequency
5) Item / Product Description
Ordering Frequency
Auto-Ship?
If 'Yes', what frequency

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