Pharmaceutical Returns (800) 215-5878
Pharmaceutical Returns

Instructions:

1. Fill out the form to the right and click "Submit" or print a .pdf version of this form and fill it out.

2. As the “contact name,” use the name of the person who will be handling the returns for your facility. INCLUDE A PHOTOCOPY OF YOUR FEDERAL DEA LICENSE FOR OUR RECORDS.

3. Under “Wholesaler Information,” complete ALL the requested information, and be sure to include your Wholesaler Account Number. If you purchase through more than one Wholesaler, complete the information of the Wholesaler you want your credit(s) to be issued through. COST CODES ARE REQUIRED TO INSURE THE ACCURACY OF YOUR RETURN.

4. After you have completed the Sign-up form, hit the submit button and you will be registered with Pharmaceutical Returns Service. For registering on-line you will receive a 25% discount on your returns. A representative will contact you within 24 hours to assist you with your first return.

New Customer Sign-up Form

If you'd prefer, you may also print a .pdf version of this form and fill it out.

After you have completed the Sign-up form, hit the submit button and you will be registered with Pharmaceutical Returns Service. For registering on-line you will receive a 25% discount on your returns. A representative will contact you within 24 hours to assist you with your first return.

Customer Information
Facility Name :
Address:
City: State:
Zip Code:
Phone #:
Fax #:
Contact Name:
DEA #:
Exp. Date:
Cost Code:
Wholesaler Information
Wholesaler Name:
Address:
City: State:
Zip Code:
Phone #:
Account #:
Direct Accounts
Manufacturer:
Account #:
Manufacturer:
Account #:
Manufacturer:
Account #:
Verification Image
 


NOTE: Please print before submitting if you'd like to retain a copy for your records.

 

Thank you for choosing Pharmaceutical Returns Service!