Sign up as a Vendor — Rx Trade Solutions

1

Account

Create your login credentials. Password must be at least 6 characters.

Name*Email*

Password*

Confirm Password*

2

Supplier

Tell us about your business.

Supplier Name*Supplier DBA (if applicable)

3

Main Contact

Main Contact Name*

Main Contact Phone Number*Main Contact Email*

4

Billing Department

Billing Department Name*

Billing Dept Phone Number*Billing Dept Email*

5

Business Address

Street Address*

WebsitePostal Code*

City*State*

6

Shipping Address

Where orders will ship from.

Same as business address

7

Billing Address

Where remittance and invoices are sent.

Same as business address

8

Business & Licenses

Wholesale license is required. DEA is optional — but if provided, all DEA fields must be filled.

Years in Business*

Wholesale License Number*License Expiration Date*

DEA Number (optional)DEA Expiration Date (optional)

9

Document Uploads

Attach your wholesale license (required). DEA document is optional.

Wholesale License Document

Drag your wholesale license here or click to browse

.jpg, .png, .jpeg, .pdf

DEA Document (optional)

Drag your DEA document here or click to browse

.jpg, .png, .jpeg, .pdf

10

Inventory & Compliance

A few quick questions about your offerings.

11

Disclosures

Required regulatory information.

What licenses does your company hold? (Wholesale, 3PL, etc. — include details)Has your company had any citations and/or offenses on record? (If yes, specify dates and occurrences)In the last 3 years, has any officer or principal of the company been disciplined for any violation of laws pertaining to DCSCA or any healthcare governing body? (If yes, please provide details)

12

Agreement

Authorized Signer Name*I have read and agree to the Terms and Conditions

List your inventory