Avenacy Direct Order Form

Direct Sales Order Form
Order Date*

MonthDayYear
Date
PO #*
PO #
Avenacy Sales Rep
Account W-9

Cancelof
SHIP TO INFORMATION
Facility Name*
Shipping Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
BILL TO INFORMATION
Same as Ship To

Yes
Company Name*
Billing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHARMACY CONTACT
Full Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
ACCOUNTS PAYABLE CONTACT
Full Name*

First NameLast Name
Phone Number*
E-mail*
example@example.com
PHARMACY INFORMATION
DEA #*
Pharmacy License #
HIN #
DUNS #
GPO
Wholesaler
DSCSA CONTACT
Full Name*

First NameLast Name
Title
Phone Number*
E-mail*
example@example.com
PRODUCTS

Please check desired product(s) and select quantity*

BIVALIRUDIN FOR INJECTIONNDC: 83634-40-010 | Pack Size: 10 | Each Price: $37.50

$375.00 QuantitySTRENGTH
Item subtotal:$0.00

DESMOPRESSIN ACETATE INJECTION, USP Product Image

DESMOPRESSIN ACETATE INJECTION, USPNDC: 83634-45-101 | Pack Size: 10 | Each Price: $12.35

$123.50 QuantitySTRENGTH
Item subtotal:$0.00

DESMOPRESSIN ACETATE INJECTION, USP NDC: 83634-45-110 | Pack Size: 1 | Each Price: $123.50

$123.50 QuantitySTRENGTH
Item subtotal:$0.00

EPTIFIBATIDE INJECTIONNDC: 83634-30-151 | Pack Size: 1 | Each Price: $46.85

$46.85 QuantitySTRENGTH
Item subtotal:$0.00

FOSAPREPITANT FOR INJECTION Product Image

FOSAPREPITANT FOR INJECTIONNDC: 83634-77-610 | Pack Size: 1 | Each Price: $15.75

$15.75 QuantitySTRENGTH
Item subtotal:$0.00

FULVESTRANT INJECTIONNDC: 83634-20-374 | Pack Size: 2 | Each Price: $65.00

$65.00 QuantitySTRENGTH
Item subtotal:$0.00

FUROSEMIDE INJECTION, USPNDC: 83634-30-210 | Pack Size: 25 | Each Price: $1.39

$34.73 QuantitySTRENGTH
Item subtotal:$0.00

ISOPROTERENOL HCL INJECTION, USP Product Image

ISOPROTERENOL HCL INJECTION, USPNDC: 83634-30-301 | Pack Size: 10 | Each Price: $45.00

$450.00 QuantitySTRENGTH
Item subtotal:$0.00

ISOPROTERENOL HCL INJECTION, USPNDC: 83634-30-305 | Pack Size: 10 | Each Price: $47.50

$475.00 QuantitySTRENGTH
Item subtotal:$0.00

MAGNESIUM SULFATE IN WATER FOR INJECTION Product Image

MAGNESIUM SULFATE IN WATER FOR INJECTIONNDC: 83634-50-081 | Pack Size: 24 | Each Price: $2.12

$50.75 QuantitySTRENGTH
Item subtotal:$0.00

MAGNESIUM SULFATE IN WATER FOR INJECTIONNDC: 83634-50-082 | Pack Size: 24 | Each Price: $2.13

$51.00 QuantitySTRENGTH
Item subtotal:$0.00

MAGNESIUM SULFATE IN WATER FOR INJECTIONNDC: 83634-50-181 | Pack Size: 24 | Each Price: $2.30

$55.00 QuantitySTRENGTH
Item subtotal:$0.00

MELPHALAN HCL FOR INJECTION Product Image

MELPHALAN HCL FOR INJECTIONNDC: 83634-20-261 | Pack Size: 1 | Each Price: $96.10

$96.10 QuantitySTRENGTH
Item subtotal:$0.00

PALONOSETRON HCL INJECTION Product Image

PALONOSETRON HCL INJECTIONNDC: 83634-77-705 | Pack Size: 1 | Each Price: $6.95

$6.95 QuantitySTRENGTH
Item subtotal:$0.00

PROCHLORPERAZINE EDISYLATE FOR INJECTION, USP Product Image

PROCHLORPERAZINE EDISYLATE FOR INJECTION, USPNDC: 83634-77-802 | Pack Size: 10 | Each Price: $2.58

$25.75 QuantitySTRENGTH
Item subtotal:$0.00

TRANEXAMIC ACID INJECTIONNDC: 83634-40-110 | Pack Size: 10 | Each Price: $2.75

$27.75 QuantitySTRENGTH
Item subtotal:$0.00

Enter coupon

Subtotal

$0.00

Shipping

$0.00

Total

$0.00

SHIPPING SPEED
Shipping*
- Standard Ground Shipping is included at no additional charge for orders over $500
- Second Day and Overnight Shipping charges will be applied to the customer’s final invoice at the time of shipping (not included above)
- Refrigerated products only ship Monday and Tuesday for 2-day delivery (no additional fee for orders over $500)
TERMS FOR DIRECT SALES
- Direct Payment Terms Are: Net 30 days. Customer shall pay Avenacy a late charge on any past-due amounts at the rate of 1.5% per month or the max permitted by law, whichever is less.
- Minimum of $500 or more per purchase order # or will be assessed $50.00 shipping fee
- Expedited shipping and orders less than $500 shall be shipped at the Customer's expense
- All product sales are final
Direct Order Remittance Address:
Eversana Life Science - Avenacy
PO Box 738034
Dallas, TX 75373-0834
To receive the necessary serialized data for product shipments, please contact jbennett@avenacy.com for information regarding the onboarding process.
Order Notes
Avenacy Information
Avenacy W-9
Should be Empty:

Direct Sales Order Form

SHIP TO INFORMATION

BILL TO INFORMATION

PHARMACY CONTACT

ACCOUNTS PAYABLE CONTACT

PHARMACY INFORMATION

DSCSA CONTACT

PRODUCTS

SHIPPING SPEED

TERMS FOR DIRECT SALES