Alethia Scripts

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Shipping Info

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Last Name *
Company
Address Line 1 *
Address Line 2
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Phone

Billing Info

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Payment

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Business Info

Legal Name *
Business Address
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Business Description
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GLIN # *
Years in business *
DEA License # *
State BOP lic. # *
State Pharmacy License (upload)

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DEA License (upload)

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Other Info

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Business Phone *
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Owner's Name
Account payable manager *
PIC Name *

Trade Reference

Primary Wholesaler
Account #1
Secondary Wholesaler
Account #2

Account

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