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 ___
ACTUAL SQUARE FOOTAGE: ___________sq/ft - OR - APPROXIMATE STORE SIZE (sq. ft.):
DOES YOUR STORE DO: COMPOUNDING: Yes No DME: Yes No
GREETINGCARDS: American Greetings Designer Greetings Other___________________
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