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Pharmacy Registration
*
Indicates a required field.
Specify the detail information about the organization in the designated fields.
*
Business name
Description
*
Address
*
City
*
Province
*
Country
*
Postal code
Phone number
(xxx-xxx-xxxx)
E-mail address
Fax number
(xxx-xxx-xxxx)
Specify the detail information about the Shipping Address in the designated fields.
same as business address above
*
Shipping Address
*
City
*
Province
*
Country
*
Postal code
Specify the detail information about your business in the designated fields.
*
Pharmacy Accreditation Number
*
Pharmacy Accreditation Expiry Date
(yyyy-mm-dd)
*
Year Established
(yyyy-mm-dd)
*
Type of Pharmacy
Independent Pharmacy
Chain Pharmacy
Specify the detail information about the Business Owner in the designated fields.
Title
Mr.
Mrs.
Ms.
Dr.
First name
*
Last name
Specify the detail information about the Business Manager in the designated fields.
same as ownername above
Title
Mr.
Mrs.
Ms.
Dr.
First name
*
Last name
Specify the detail information about the administrator in the designated fields.
*
User ID
*
Password
*
Verify password
*
Employee ID
Title
Mr.
Mrs.
Ms.
Dr.
First name
*
Last name
*
Address
*
City
*
Province
*
Country
*
Postal code
Phone number
(xxx-xxx-xxxx)
*
E-mail address
Internal mailing address
Job function
Senior Management
Middle Management
Pharmacist
Pharmacy Technician
Buyer
Other
Submit
