New Customer Signup - Nephron Pharmaceuticals

Company Name *

Only lower case letters (a-z) and numbers (0-9) are allowed.

Customer Type

DEA #

Pharmacy License #

Pharmacy License Expiry Date

GPO/Health System

Primary Contact First Name *

First

Primary Contact Last Name *

Last

Primary Contact Title *

Only lower case letters (a-z) and numbers (0-9) are allowed.

Primary Contact Email Address *

Enter Email

Confirm Primary Contact Email Address *

Confirm Email

Accounts Payable Email

Phone

Fax

Primary Address

City

State/Province

Zip/Postal

Shipping Address

City

State/Province

Zip/Postal

Country | NOTE : All US ship to locations must be listed and have a current Board of Pharmacy license on file. Please email all Board of Pharmacy licenses to NOFAccounts@nephronpharm.com. If your company has EDI capabilities, please include the DEA # on this form and contact EDISupport@nephronpharm.com.

Accounts Payable Address

City

State/Province

Zip/Postal

Country