Step 1 of 5 20% Name* First Last Email* Phone*Number of Pharmacy Locations* If you have multiple Pharmacy locations, please upload a list of them here including their full addresses:Max. file size: 50 MB.Pharmacy Name* Website Address* Job Title* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Wholesaler* Secondary Wholesaler* What is your monthly brand rebate percentage?What is your monthly generic rebate percentage?When does your contract expire? MM slash DD slash YYYY Do you receive any tech rebate, other fees, or discounts from your primary? Yes No What is your gross total purchasing volume for all pharmacies?What is your current discounted cost of goods? DEA # What are your top 3 concerns?How did you hear about us? Does your business require licensing? Yes No Please list licensesDate license issued? MM slash DD slash YYYY License expiration date? MM slash DD slash YYYY Description of Services/Products:Your Service Areas?Employer Identification Number (EIN): Date business first started? MM slash DD slash YYYY Number of employees? Number of customers? Anything else we should know about your business? Please explain if so. Pharmacy Software Provider Insurance Provider What Marketing Are You Currently Doing?Do you have a marketing agency now? If so, who do you use?What are you looking to achieve from your membership?Please list any comments that will help us understand your needs.Membership Options*Patient Engagement SolutionsPrescriber Engagement & Clinical SolutionsInsured GPO & Business Management PlatformPrice is per month.Terms & Conditions* I agree to the terms and conditions of APPA membership.Company Background Check* I understand that APPA may run a company background check if necessary.Total $0.00 EmailThis field is for validation purposes and should be left unchanged. Δ
