Wholesale Pharmaceuticals, Medical/Dental Supplies, Disposables

Become an MPS Client

Please fill in the form below and we will contact you with your own Client Account Number.

ANAF File
 
Account No
Account Mgr
 

Primary Contact Info

Company*
Contact* First Last
Title (DMD, DDS, MD, RN, etc. 20 chars max)
Phone* (###-###-####)   Ext
Fax* (###-###-####)   No Fax No Fax Number
Email*
Tax ID* (Tax ID or SSN)
Payment (Additional payment information can be provided later)
 

Additional Contacts

If there are staff members who should be contacted for specific tasks, please enter them here.
Other Contacts Enter Other Contacts
Accounts Payable
Full Name
Phone (###-###-####) Ext:
Fax (###-###-####)
Email
 
Licensure
Full Name
Phone (###-###-####) Ext:
Fax (###-###-####)
Email
 
E-Tracking
Full Name
Phone (###-###-####) Ext:
Fax (###-###-####)
Email
 
Package Inserts
Full Name
Phone (###-###-####) Ext:
Fax (###-###-####)
Email
 
CodeBlue
Full Name
Phone (###-###-####) Ext:
Fax (###-###-####)
Email
 
Credit Card
Full Name
Phone (###-###-####) Ext:
Fax (###-###-####)
Email
 

Shipping Info

Address*
  NOTE: Please enter your suite number in the field above.
Address 2
City*
State*
Zip Code*

Billing Info

Use Shipping
Use Shipping
Address*
  NOTE: Please enter your suite number in the field above.
Address 2
City*
State*
Zip Code*

DEA License

No DEA No Fax Number
Number*
Expires* (mm/dd/yyyy)
DEA License name as it appears on the License
Name*

State License

Number*
Expires* (mm/dd/yyyy)
State License name as it appears on the License
Name*

Primary Practice

Please indicate your primary practice type. We may use this to better tailor your experience on the website.

Website Passwords

Select a master password for access to the MPS and CodeBlue websites. This password gives you access to formulary management, online ordering, package tracking, statements, purchase history, and the CodeBlue Monitoring Service website.
MPS.com
Confirm
Select a password for access to our CodeBlue Monitoring Service website.
CodeBlue.com
Confirm

How did you hear about Medical Purchasing Solutions?

Source
Referral Type

Internal Notes

Documents

Copies of your DEA Certificate and State License may be faxed to (800) 351-0834, Emailed, or uploaded.
We will need this information to finalize the account.






  Create AMP Account Create AMP Account