Register
Business Name & DBA (If different) *
Billing Address
Shipping Address
Phone
Fax
Mobile
Pharmacy License Number
DEA Number
Hours
Daily Scripts
Pharmacy Manager License
Pharmacy Manager Name
Should we charge tax?
Tax I.D.
Class of trade
How Long In Business?
How did you hear about us?
Do you own any other facilities?
Form of Ownership
Duns
Owner/Registered Agent
Cell
Email
Purchasing Contact
Cell
Email
A.P. Contact
Cell
Email
Clinic/Pharmacy Manager
Cell
Email
Pharmaceutical trade references
Trade Reference 1
Trade Reference 2
Trade Reference 3
Payment Option
Credit Card Form
Company name (s):
Phone
Cellphone
Email
Adress
City
State
Zip Code
Credit Card
Card number
Name as it appears on the card
Expiration date
Security code
City
State
Zip Code
Customer account number (s) with Paragon:
Signed
Date
ACH Form
Company name (s):
Phone
Cellphone
Email
Adress
City
State
Zip Code
Bank name
Bank Branch
City
State
Zip Code
Bank Transit/ABA/ACH Routing #:
Bank Account #
Customer account number (s) with Paragon:
Signed
Date