Request Form - Retail Pharmacy Services
Required fields denoted by *
Name*
Title
Store/Company/Chain Name*
Address
Street : City : State : Zip :
Phone*
Fax
E-Mail*
How Did You Hear of PRS?
*
AmeriSource Bergen
Cardinal Health
Mailing
PRS Client (Please Specify in Comments Below)
SuperValu Wholesaler
Topco Associates
Trade Show (Please Specify in Comments Below)
United Drugs
Other (Please Specify in Comments Below)
# of Stores
Approximate Size(s)
Do You Currently Have a Pharmacy?
Yes
No
# Leased
# Owned
Primary Grocery Wholesaler
HBC Supplier
What Options Are You Interested In:
(check all that apply)
Retail Pharmacy Development Program
On-Site Pharmacy Evaluation
Prescription Pricing Program
Pharmacy Monitoring Program
Marketing Program
Inventory Control Program
HIPAA Compliance Program
Pharmacy Acquisition
Residential Care Pharmacy Development Program
Other Requests/Comments
