IPBG : Independent Pharmacy Buying Group

*First Name:	*Last Name:
*Pharmacy Name:
*Pharmacy Address:

*City:	, State: Zip Code:
Email (Automatic lowercase*):	*Confirm Email Address:
*Contact Phone Number:	ext.
Best time to contact you: Morning Afternoon Evening Anytime

To help us determine how we can benefit you please provide the following information if available.

Primary Drug Wholesaler:
Average Monthly Purchases:
Cost Minus Percent:
Percent Rebate on Generics From Wholesaler:
Generic Drug Wholesaler:
Average Monthly Purchase:
How did you find Independent Pharmacy Buying Group?

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