Supplier Questionnaire Supplier Name (Legal Name) * Supplier Name (DBA Name, If Different) Owner Name * Owner Phone Number * Main Contact Name (If Different) Main Contact Phone (If Different) Main Contact Email * Main Contact Title * Billing/Finance Contact Name * Billing/Finance Contact Phone * Billing/Finance Contact EMail * Billing/Finance Contact Email (Alternate Email) Street Address * City * State * Zip * Fax Number Website * Years In Business (2+ Required) * Total Annual Sales ($) * Number of Division(s) / Locations * Size of Warehouse Facility (Square Feet) * Do you offer Controlled Substance Medications? * Yes No Do you offer Generics? * Yes No Do you offer Brands? * Yes No Do you offer OTC’s? * Yes No Do you offer DME’s? * Yes No Business Mix Pharma % * 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Business Mix Home Health % * 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Business Mix Other % * 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Business Mix Other Explanation (If Other) How many product SKU’s are in your catalog? * Number of States Licensed to Distribute in? * ADD-Accredited? * Yes No Pending DEA Licensed? * Yes No Pending What credit terms do you offer new customers? (Separate by Comma) * Payment Methods Accepted? (Separate by Comma) * Can you accept Trxade’s Universal Credit Application? * Yes No Need To Review What is your order minimum for Next Day shipping? * Daily Cut-off Time (EST Time) * 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 9pm 10pm 11pm What Software System do you use to process orders? * How will you load your catalog? * API EDI Manually (via Trxade.com) FTP Dropbox Are you able to provide Pedigree (T3) on all Rx purchases? * Yes No Pending Not Needed For Our Products DSCA Compliant - If yes, what system are you using to generate pedigrees and how will they be issued to buyers?
What licenses does your company hold? (Provide details: Wholesale, 3PL, Etc.) *
Has your company had any citations and/or offenses on record? (If yes, please specify dates and occurrences) *
In the last 3 years has any officer or principal of the company been disciplined for any violation for laws pertaining to DCSCA or any healthcare governing body? (If yes, please provide details) * Manufacturer Affiliations (If Any) Buying Group Affiliations (If Any) Do you hold the same address as a pharmacy? * No Yes Do you buy Rx from Pharmacies to resell? * No Yes Do you do business with government entities? * No Yes When was your last Inspection by the State? * 0-6 Months 6-12 Months 12-24 Months
Important: Please email photographs of your Warehouse, 3 pedigree/T3 examples, and a copy of your last inspection by the board of pharmacy to Operations@Trxade.com to help expedite your application.
Photographs Needed: Outside of Building, Customer Service Area, Warehouse Facility, & Shipping Area