Retailer Registration

Please fill out the form below and a representative from our team will be in touch on your account approval process.

"*" indicates required fields

Name*

Phone*

Email*

Company Name*

Address*

Street Address Address Line 2 City State ZIP Code

Pharmacy EIN Number

Were you referred to PharmaCentrix by a Distributor?*

Yes, Keysource

Other

Username*

Password*

Enter Password Confirm Password

Comments/Questions

This field is for validation purposes and should be left unchanged.