New Account Form — Pharm House Supply

Supplying fast and affordable drugs you regularly need in Texas

Organization/Company Name

State Tax ID

Primary Contact

First Name

Last Name

Title

Work Phone

(###)

###

####

Cell Phone

(###)

###

####

Address

Address must exactly match address on license.

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Additional Authorized Buyer on Account

First Name

Last Name

Additional Authorized Buyer on Account

First Name

Last Name

When possible, please communicate with me via:

Phone

Best email or phone to reach me directly

License #

A copy of license must also be provided via email

Exp. Date

YYYY

Accounts Payable:

First Name

Last Name

Fax

(###)

###

####

Pharmacy Owner

First Name

Last Name

Pharmacy Manager

First Name

Last Name

Please complete this form and email a copy of all licenses to sales@pharmhousesupply.com.

Accredited Distributor