PGL Test Create an Account - Pharmagenetico CREATE AN ACCOUNT PHARMACY LOGIN Intelligent Pharmaceuticals MENU ABOUT US QUALITY & COMPLIANCE PRODUCTS CONTACT US REPORT AN ADVERSE EVENT Create an Account Thank you for your interest in PharmaGenetico's products. To create an account and start ordering products, provide your pharmacy information in the fields below. Company InformationLegal Name of Business*Pharmacy Name (if different)Date Opened* License #*Type of Pharmacy*Pharmacist in Charge (Last, First)*Phone*Email* Billing InformationBilling Address* Street Address City State Zip Code Shipping AddressShipping Address* Street Address City State Zip Code Bank InformationBank Name*Account Number*Bank Address* Street Address City State Zip Code Contact NamePhone Trade ReferencesCompany Name Contact Name Contact Phone NumberContact Address Street Address City State Zip Code Date Account Opened Credit LimitCompany NameContact NameContact PhoneContact Address Street Address City State Zip Code Date Account Opened Credit Limit Federal DEA Certificate & State LicensesFederal DEA Certification Number*State License Number*
