Wholesale Pharmaceuticals Since 1973 • DEA #: PA0021179

New Business Partner Application

Please complete all applicable sections. Incomplete, inaccurate, or expired licensing information may delay account approval or order processing.

1. Account Type

Select the option that best describes your practice or business model *

2. Number of Business Locations & States

How many clinic / practice locations or states does your business operate in? *

3. Business / Bill-To Information

Required for all accounts

4. Primary Contact / Purchaser

Designated ordering and account contacts

5. Ship-To Location

Physical delivery address and receiving schedule for shipments

Specify delivery receiving hours for each day of the week (Monday through Sunday). Check "Closed" for non-operating days.

Day of Week
Status
Operating Hours
Summary
Monday
to
8:00 AM – 5:00 PM
Tuesday
to
8:00 AM – 5:00 PM
Wednesday
to
8:00 AM – 5:00 PM
Thursday
to
8:00 AM – 5:00 PM
Friday
to
8:00 AM – 5:00 PM
Saturday
to
Closed
Sunday
to
Closed

6. Medical Director / Prescriber Information

Physician / Prescriber licensing and physical practice address

Optional: Attach Medical Director State License & DEA Certificate

If you already have a copy of your Medical Director's State Medical License or DEA Certificate on file, you may attach them here. This pre-fills the documents in your physician's verification portal so they only need to review and sign.

Medical Director Attestation & Document Upload Notice

Upon submission of this application, an automated invitation email will be sent directly to your Medical Director at the email address provided above. They will be prompted to access a secure attestation portal to review details, draw their digital signature, and upload copies of their State Medical License and DEA Certificate.

7. Licensed Provider Information

Required for Mobile IV Companies / individual licensed providers, when applicable

Provide the credentials for administering or practicing clinicians (EMCT, MD/DO, NP, PA, RN). Additional providers may be submitted separately. Apotheca may require verification of any license, registration, or credential provided.

8. Accounts Payable / Payment Information

Billing contacts and payment terms acknowledgment

Payment Terms: Pay Per Order

New accounts are established as Pay Per Order unless different terms are expressly approved by Apotheca, Inc. in writing. Approval of an account does not constitute approval of credit terms.

Payment Setup: Credit Card Authorization

To streamline onboarding, credit card authorization is collected securely following account approval. Once your medical credentials are confirmed, your Accounts Payable contact will receive a secure portal link to submit payment authorization before order release.

9. Account & Compliance Certifications

Please confirm each required compliance statement *

10. Terms & Conditions, Return Policy & Applicant Acknowledgment

Please read in its entirety and confirm acceptance

Terms and Conditions

1. Account Acceptance: This application is for direct ordering of pharmaceutical products and is subject to acceptance by Apotheca, Inc. Apotheca may verify information and credentials provided in connection with the application and may approve, deny, restrict, suspend, or place an account or order on hold when necessary for payment, licensing, regulatory, operational, or compliance reasons.

2. Pricing and Order Terms: Pricing and terms related to the sale of products are subject to change. If this application is accepted, the approved account holder and its representatives agree to be bound by the terms and conditions prevailing at the time of each order. The account holder is responsible for reporting discrepancies promptly.

3. Licenses, Locations, and Authorized Users: The account holder is responsible for maintaining all licenses, registrations, permits, and authorizations required for its business and purchases. The account holder must notify Apotheca promptly of changes affecting ownership, Medical Director/prescriber, providers, licenses, DEA registration, billing information, or ship-to locations. Account approval may not be transferred to another business, provider, or location without Apotheca's approval.

4. Payment: Unless otherwise approved by Apotheca in writing, orders are Pay Per Order and must be paid before release or shipment. Any alternative payment or credit terms must be approved in writing. Collection costs and fees incurred on delinquent accounts are the responsibility of the account holder to the extent permitted by applicable law.

Return Policy

5. Returnable Items: Products must be in sealed, original containers in resaleable condition and must be accompanied by an approved Return Authorization Form or Destruction Authorization Form. Short-dated or expired product may receive no credit or may be subject to a restocking fee and/or destruction fee.

6. Special Order / Non-Stock Items: Items considered special order or non-stock must be authorized for return or cancellation by Apotheca prior to return. Such products may be subject to a restocking fee and may be non-returnable depending on manufacturer or supplier restrictions.

7. Non-Returnable Items: Products returned without approved authorization, products in unsaleable condition (including broken seals, opened or soiled packages, price labels or other markings), products stored under improper conditions, discontinued products sold on a non-returnable basis, unauthorized special-order/non-stock items, and products involved in bankruptcy sales may be non-returnable.

8. Transportation / Damaged Goods: For product ordered in error by the customer, expired product, or product being destroyed, transportation is prepaid by the customer. Apotheca will be responsible for applicable shipping charges when an Apotheca order-entry error occurred, product was damaged during shipping, or product was recalled by the manufacturer, subject to applicable procedures. Damaged products returned to Apotheca must be accompanied by the required documentation.

9. Return Reporting: Damage or shortage should be reported promptly, including notification to the carrier when appropriate. Parcel shipment damage or shortage should be reported within 72 hours of receipt. Products considered for return must be reported within 5 working days of receipt. Credit is based on actual purchase price and only for items approved for return. Apotheca reserves the right to approve or deny return authorization, and returns or destructions may be subject to applicable fees.

10. Returns Address: Authorized returns are to be sent to:
Apotheca, Inc.
1622 N. 16th St.
Phoenix, AZ 85006

Customer Acceptance & Perjury Declaration

I declare under penalty of perjury that the information provided in this application is true and correct. I acknowledge that acceptance of this application is at Apotheca, Inc.'s discretion and agree that purchases are subject to Apotheca's then-current account terms, pricing, policies, and applicable law.

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