Pharmacy Wholesale Registration

Pharmacy Wholesale Registration

Register your Australian pharmacy for wholesale access to the Grenco Medical Elite II Vaporiser. Please provide your business, contact, regulatory, and consent details.
Pharmacy Business Details
Pharmacy / Trading Name
Legal Business Name
ABN
ACN
Australian Business Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Shipping Address (if different)

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Business Phone
Please enter a valid phone number.Format: (00) 0000-0000.
Business Email
example@example.com
Primary Contact and Pharmacist Details
Primary Contact Full Name

PrefixFirst NameLast Name
Job Title / Role
Direct Phone Number
Please enter a valid phone number.Format: (00) 0000-0000.
Email Address
example@example.com
Regulatory and Wholesale Eligibility Details
Pharmacist AHPRA Number
Australian Pharmacy Approval Number
If private only, please enter 'NONPBS'
State or Territory
Wholesale Eligibility Declaration
Regulatory Declarations
Copy of Pharmacy Approval Certificate

Cancelof
Consent and Account Approval
I confirm I am an authorised signatory for this application
Consent to be contacted about this application
Declaration: the information provided is true and complete
Should be Empty: