(888) 894-2487

Wholesale Pharmaceuticals, Medical/Dental Supplies, Disposables

Become an MPS Client

Use this form to request an MPS Client Account. We will verify the information and contact you when the account is ready.

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 may be provided later)
 

Additional Contacts

If there are staff members who should receive specific notifications, 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 Certificate
No DEA No Fax Number
Number*
Expires* (mm/dd/yyyy)
DEA Certificate name as it appears on the Certificate
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 both the MPS and CodeBlue websites. This password gives you full access to formulary management, online ordering, package tracking, statements, purchase history, and the CodeBlue Monitoring Service website.
Password
Confirm
Select a limited access password for just the CodeBlue Monitoring Service website. This can be used to give access to staff members who maintain your crash cart inventory.
Password
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.







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