Dispill Contract Request

CPESN NY Dispill Contract Request

Please complete questions below and a Cardinal Representative will be sending a contract for you to sign to receive 5% discount on Dispill purchases.
Name of Pharmacy (if you cannot find your pharmacy use NOT LISTED (bottom of list)*
Name of Pharmacy if not listed.
Does you pharmacy have a Prime Vendor Agreement (PVA) with Cardinal Health?*

YesNoNot sure
For purchases covered by your PVA, please provide the "SHIP TO" account number listed on a recent Cardinal invoice. *
Does your pharmacy have a Parmed account?*

YesNoNot sure
Please provide your pharmacy's Parmed account number*
Name of person who is requesting and is authorized to sign contract for the 5% Dispill discount*

First NameLast Name
Title of person who will be signing Dispill Contract*
Email of person who will be signing Dispill Contract*
example@example.com
Should be Empty:

CPESN NY Dispill Contract Request