CUSTOMER ACCOUNT APPLICATION

Open An Account

Interested in becoming a new customer? Complete the application below in just a few minutes. Daily Care Pharmacy will review your new account request and a representative will reach out to you promptly.

Application Submitted Successfully!

Thank you. Your wholesale account application has been received by Daily Care Pharmacy. Our team will review your credentials and contact you within 1–2 business days. If you have any urgent inquiries, please call us at (202) 573-4153.

Facility

Tell us about the business or healthcare entity applying for an account.

Facility / Legal Business Name *

DBA Name

Organization Type *

Federal Tax ID / EIN *

Phone *

Fax

Website

Contact Person

Key contacts for buyer purchasing and accounts payable.

Buyer Name *

Accounts Payable Name *

Buyer Phone *

Accounts Payable Phone *

Buyer Email *

Accounts Payable Email *

Shipping

Shipping address for orders and deliveries.

Address Line 1 *

Address Line 2

City *

State *

Zip *

Billing

Primary billing address for the account.

Billing address is the same as shipping address.

Address Line 1 *

Address Line 2

City *

State *

Zip *

License

Upload a current copy of your applicable healthcare license.

License Type *

Issuing State *

License Number *

Expiration Date *

Upload License Copy *

Upload as PDF, JPG, or PNG file. Maximum file size: 2 MB.

DSCSA / EPCIS

Provide DSCSA / EPCIS details if available.

GLN Number

SGLN Number

EPCIS Provider / Platform

DSCSA Contact Email

Additional Notes