\ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ \ Create New Customer Account

JavaScript seems to be disabled in your browser. For the best experience on our site, be sure to turn on Javascript in your browser.

Create New Customer Account

Personal Information

First Name

Last Name

Login Information

Email

Password

Password Strength: No Password

Confirm Password

Are you a UPN Member

\

Type of Account

Buyer
Seller
Buyer / Seller

Seller Type

Shop Name

Legal Business Name

Legal Business Name

DBA Name

Address 1

DBA Name

Address 1

Address 2

City

Address 2

City

State

State

Zip

Zip

USA

USA

Business Phone

Business Phone

Business Fax

Business Fax

Business Email

Federal Tax Id

Business Email

DEA

DEA

DEA Expiration Date

DEA Expiration Date

Business Licence

Pharmacy License

Business Licence Expiration Date

Pharmacy License Expiration Date

DEA License Copy ( jpg, jpeg, png )

Allowed File Types: jpg,jpeg,png

Maximum File Size Allowed: 7MB

DEA License Copy ( jpg, jpeg, png )

Allowed File Types: jpg,jpeg,png

Maximum File Size Allowed: 7MB

State License Copy ( jpg, jpeg, png )

Allowed File Types: jpg,jpeg,png

Maximum File Size Allowed: 7MB

State License Copy ( jpg, jpeg, png )

Allowed File Types: jpg,jpeg,png

Maximum File Size Allowed: 7MB

NPI

NPI

NCPDP

NCPDP

Federal Tax id

Please accept PharmEtrade Terms & Conditions *

Type of Account

Yes No