Central Fill Pharmacy Agreement

Central Fill Pharmacy Agreement
Last updated: 2/17/26

Changelog:
- 2/17/26: removed fields for CC info due to PCI compliance risk.
- 2/8/26: Form activated
Pharmacy Name:*
Georgia Pharmacy License Number:*
Pharmacist in Charge Name:*
Pharmacist in Charge GA License Number:*
Pharmacy DEA Registration Number:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy Phone Number:*
Format: (000) 000-0000.
Pharmacy Fax Number:*
Format: (000) 000-0000.
Primary Contact Email:*
example@example.com
If you would like to add additional contact(s), please list their information below:
For additional staff, billing, etc.
Effective March 2026, all new facility clients will be invoiced monthly (Net 30). If you need an alternate arrangement, please contact us at 706-521-0272 or compounding@hawthornedrugs.com.
ACH transferCredit cardInvoice (Net 30)CheckOther
Signatures
Designated Person Name*
Designated Person Title*
Effective Date*

MonthDayYear
Date
Automatic annual renewalUse another expiration date (specify)
Signature*

Clear
Central Fill Pharmacy
Designated Person Name:
Designated Person Title:
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty: