Warehouse/Affiliate Application

Surecost Program Participant

Questions? Need Help? 1.800.755.1531

Store Details

Pharmacy Name

Pharmacy Name is required.
Corporate Name

Corporate Name is required.
Primary Wholesaler

Owner

Location

Shipping Address
- Address
  
  Address is required.
- City
  
  City is required.
- State
  
  State is required.
  
  Zip Code
  
  Zip Code is required.
- Phone
  
  Phone is required.
- Fax
  
  Fax is required.
Billing Address
Same as shipping address?
- Yes
- No
- Address
  
  Address is required.
- City
  
  City is required.
- State
  
  State is required.
  
  Zip Code
  
  Zip Code is required.
- Phone
  
  Phone is required.
- Fax
  
  Fax is required.

Store Questions

Do you currently own another pharmacy(ies) and/or corporation that is already a member of IPC?
- Yes
- No
Please list the pharmacy(ies) and/or corporation(s):
Have you, co-owners, shareholders, or managers ever been convicted of a felony, or had your license revoked or suspended in the last 10 years?
- Yes
- No
Please explain:
Have you, co-owners, shareholders, or managers ever filed for bankruptcy?
- Yes
- No
Date Filed

Year must be after 1900
Please explain:

License Information

DEA #

DEA # is not a valid number.

Exp. Date

Year must be after 1900
DEA Document
- Add Attachment
NCPDP #

NCPDP # is not a valid number.

Medicare Part B #

Medicare Part B # is not a valid number.
NPI #

NPI Number is not a valid number.
State Sellers Permit #

State Sellers Permit # is not a valid number.
State Sellers Permit Document
- Add Attachment
Pharmacy License #

Pharmacy License # is required.

Exp. Date

Year must be after 1900
Pharmacy License Number
- Add Attachment

W-9 Information

Download current fillable W-9 form: https://www.irs.gov/pub/irs-pdf/fw9.pdf
Select at least one of the following:
- Individual / Sole Proprietor or Single-Member LLC
- C Corporation
- S Corporation
- Partnership
- Trust / Estate
- Limited Liability Company
A selection is required.
SSN / EIN

SNN / EIN is required.
W-9 Document
- Add Attachment
  
  W-9 Document is required.

ACH Debits and/or Credits

ACH Rebate Payout = 45 days from month end

With ACH processing, your rebate funds are immediately available 45 days from the end of the qualifying month's sales.
Please select one of the following:
- Standard ACH Account Terms
  
  45 days dating for Rx Generic orders, 21 days dating for Rx Brand orders, 30 days for OTC orders, 30 days for all other IPC programs apply for ACH invoicing and rebates: I am a new ACH participant and currently do not have an ACH account authorized with IPC. Please utilize below information for ACH invoices and rebates (debits/credits).
- ACH Account Net 7 Terms
  
  7 days dating for all IPC invoices. I am a new ACH participant and currently do not have an ACH account authorized with IPC. Please utilize below information for ACH invoices and rebates (debits/credits) for all IPC programs and services.
- Statement Billing
  
  I agree to utilize statement billing for all of the IPC programs and services and I agree to the following ACH payment system that will be applied to all IPC invoices:
  - All IPC invoices dated the 1st thru the 15th of the month – deducted on the 20th of the month.
  - All IPC invoices dated the 16th thru the end of month – deducted on the 5th of next month.
  - I also understand that my rebates, if applicable, will be deposited ACH. I have designated the below account(s) for ACH.

Credit Reference Information

Bank Name

Bank Name is required.
Account 1

Account 1 is required.
Account 2

Account 2 can only contain digits.
Phone

Phone is required.
Bank Contact Name

Bank Contact Name is required.
City

City is required.
State

State is required.

Zip Code

Zip Code is required.

ACH Accounts

Account information will be used for ACH invoices and rebates (debits/credits) for all IPC programs and services.
ACH Account #1
- - Use bank information from the Credit Reference Information section.
- Account Type
  - Checking
  - Savings
    
    Account Type is required.
- Bank Name
  
  Bank Name is required.
- Branch
  
  Branch is required.
- City
  
  City is required.
- State
  
  State is required.
  
  Zip Code
  
  Zip Code is required.
- Transit/ABA #
  
  Transit/ABA # is required.
- Account #
  
  Account # is required.
- - Add Attachment
- Wholesaler Statements
  (two consecutive required)
  - Add Attachment
    
    Wholesaler Statement is required.
- Use this account for
  
  Use this account for is required.
Would You Like to add a 2nd ACH Account for
- Yes
- No
ACH Account #2
- This account will be used for IPC Rebates
  
  This account will be used for IPC Invoices
- - Use bank information from the Credit Reference Information section.
- Account Type
  - Checking
  - Savings
    3
    
    Account Type is required.
- Bank Name
  
  Bank Name is required.
- Branch
  
  Branch is required.
- City
  
  City is required.
- State
  
  State is required.
  
  Zip Code
  
  Zip Code is required.
- Transit/ABA #
  
  Transit/ABA # is required.
- Account #
  
  Account # is required.
- - Add Attachment

Store Information

Store Details

Pharmacy Name
Corporate Name
DC
Primary Wholesaler

Edit

Owner

Owner/Officer/Agent Name
Owner/Officer/Agent Email Address
The Owner/Officer/Agent is also the:

President
Co-Owner Name
Co-Owner Email Address
The Co-Owner is also the:

Edit

Shipping Address

Address
Phone
Fax

Edit

Billing Address

Address
Phone
Fax

Edit

Store Questions

- Do you currently own another pharmacy(ies) and/or corporation that is already a member of IPC?
- Please list the pharmacy(ies) and/or corporation(s):
- Have you, co-owners, shareholders, or managers ever been convicted of a felony, or had your license revoked or suspended in the last 10 years?
  
  Yes
- Please explain:
- Have you, co-owners, shareholders, or managers ever filed for bankruptcy?
  
  Yes
- Date Filed
- Please explain:

Edit

License Information

ID Numbers

NCPDP #
Medicare Part B #
NPI #

Edit

DEA

DEA #
Exp. Date
DEA Document

Edit

State Sellers Permit

Permit #
Permit Document

Edit

Pharmacy License

License #
Expiration Date
Pharmacy License Attachment

Edit

W-9 Information

Federal Tax Classification
SSN / EIN
Pharmacy License Attachment

Edit

Credit Application

Account Details

ACH Debits and/or Credits selection

Edit

Credit Reference Information

Bank Name
Account 1
Phone
Bank Contact Name
Location

Edit

ACH Account #1

Account Type
Bank Name
Branch
Location
Transit/ABA #
Account #
Voided Check

Wholesaler Statements

Edit

ACH Account #2

Account Type
Bank Name
Branch
Location
Transit/ABA #
Account #

Edit

Before you begin...

We recommend having the following documents ready.

Pharmacy
License
State Sellers
Permit
DEA
Document
W-9
Check/Deposit Slip

For your ACH account(s)

To protect your information, your progress will not be saved until you review and submit your application.

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