Rx3 New Office Information Sheet

Rx3 Pharmacy New Office Information Sheet
Name of Office*
Office Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Office Fax (if you have one)
Please enter a valid phone number.Format: (000) 000-0000.
Office Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
YesNo
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Office AddressBilling AddressOther
Shipping Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Prescriber*
DEA Number*
NPI Number*
Other (Potential) Prescribers
Point of Contact Name*

First NameLast Name
Point of Contact Email*
example@example.com
Point of Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
To help ensure the appropriate process is followed, when submitting orders please include where we are to ship the product (or if the patient is picking it up) and who is paying for it. We have some offices that sometimes pay for and receive items and sometimes have the patient pay for and receive items, etc. Making this clarification on each order helps us take the appropriate actions.
Notes for Pharmacy
Should be Empty:

Rx3 Pharmacy New Office Information Sheet