Rising: Customer Setup Form

Customer Setup Form
Customer Type
Legal Business Name
Doing Business As (DBA)
Business Physical Address

Street Address

Street Address Line 2

CityState

Zip Code
Is the Billing Address the same as the Physical Business Address?
Bill to Address

Street Address

Street Address Line 2

CityState

Zip Code

Business Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Fax Number
Format: (000) 000-0000.
Business Email Address
example@example.com
Are you open 24 hours?

Hours of Operation

Rows	Sunday	Monday	Tuesday	Wednesday	Thursday	Friday	Saturday
Open
Close

NPI
State Board License Number (Facility)
DEA Registration Number
Controlled Substance License Number (Facility)
Federal Tax ID

GLN (Global Location Number)

Rows	GLN (Global Location Number)
Bill to GLN
Bill to sGLN
Sold to GLN
Sold to sGLN

Medical Director Name

First NameLast Name
Medical Director State License #
Medical Director NPI
Has the Medical Director been licensed in any other state(s) in the past 2 years?
If licensed in additional states, please provide the state and license number

Pharmacist In Charge (Name)

First NameLast Name
Pharmacist In Charge License Number
Has the Pharmacist in Charge been licensed in any other state(s) in the past 2 years?
If licensed in additional states, please provide the state and license number

Ownership Type
Business Owner Name

First NameLast Name
Business Owner Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Business Owner Email Address
example@example.com
Name of Entity
State in which entity is registered
Percent Ownership
Additional Entity Owners (Total Ownership Must Equal 100%)

ACH Form - To Be added to this Page
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: