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
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