Independent Pharmacy Alliance of America Inc. President



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Independent Pharmacy Alliance of America Inc.

President

John A. Giampolo



Corp Dir of

Pharmacy Services

Daniel S. Levine, R.Ph.



Corp Dir of Operations

Kathleen A. Fuller


The Buying Cooperative




APPLICATION FOR MEMBERSHIP TO IPA

There are no dues associated with your membership to IPA.

* * * Strictly Confidential ***


Cedar Brook Corporate Center

3 Cedar Brook Drive

Cranbury, N.J. 08512

(P): 800-575-2667/(F): 609-395-1007

E-mail: info@ipagroup.org

Web: ipa-rx.org

Rev.6/26/17

Please accept my pharmacy into IPA membership with a one-time lifetime membership fee of only $7.95.

PHARMACY NAME CORP NAME

ADDRESS E-MAIL ______________________________

CITY ___________________ ST _____ ZIP CODE ___________ COUNTY

TELEPHONE _____________________ FAX _______________________ CELL (optional)

DEA # NCPDP # NPI #

(for manufacturer’s rebates)

OWNER’S NAME FRONT MANAGER


OTHER BUYING GROUP AFFILIATIONS: 1._ __ 2._ ______

A complete contract book will be sent upon receipt of this application and your check for $7.95.
CONFIDENTIAL PHARMACY PROFILE: Please fill out only those you wish to answer and estimate values for convenience.

My Current Wholesaler is: Est. Monthly Whlsr Volume: Whlsr Account #

1. $ / month ___



2. $ / month ___

  1. ACTUAL SQUARE FOOTAGE: ___________sq/ft - OR - APPROXIMATE STORE SIZE (sq. ft.):

1,000 – 2,500;  2,500 – 5,000;  5,000 – 7,000;  7,000 & up

  1. GENERIC DISTRIBTORS:  ANDA  Prescription Supply  Other: ________________

  2. VITAMINS:  Nature’s Bty  Sundown  Windmill  21st Century  Other____________

  3. INSURANCE (BOP, Professional, General Liability, Auto, etc.): Policy Expiration Date: _____________

  4. DOES YOUR STORE DO: COMPOUNDING:  Yes  No DME:  Yes  No

  5. GREETING CARDS:  American Greetings  Designer Greetings Other___________________

  6. VISA/MASTERCARD: Do you use:  Heartland Payment Sys  Global  Other_______________

Thank you for adding your strength to the over 3,100 NY, NJ, PA and CT independent pharmacies that are members of IPA. Your signature allows you to participate in any IPA program of your choice and gives IPA your consent to receive faxes sent by or on behalf of IPA. FYI: 99% of all faxes are limited to 1 page for 3rd party, legislative and co-op information. According to the Safe Harbor Regulation, we are informing you that IPA receives a small administrative fee on behalf of your purchases from the discounted contracts provided by IPA suppliers.


Please Return This Application via Mail - or - Fax to IPA at 609-395-1007


____________________

Authorized Signature Date








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