Pharmaceutical Returns Service :: Register

New Customer Registration Form

Organization Name:

Your Personal User Information

First Name:

Last Name:

Email Address:

Your Email Address will also be your username for logging into the Customer Portal.

Phone Number:

Location Information

If you have only one location, please enter your location information in the fields below. If you have multiple locations, please enter the primary location and you will be given an opportunity to add addtional locations after you have completed the initial registration process.

Location Label:

If you have multiple locations, the location label is an easy way to differientiant between then. If no Location Label is used, the location will be labelled using the Location's Address instead.

Address:

Suite/Apt:

City:

State:

Zip:

Phone:

Fax:

DEA Number:

Expiration Date:

mm/dd/yyyy

DEA License:

How would you like to provide a copy of your DEA Licence to PRS?

Pharmaceutical Returns Service - Comprehensive, Cost Effective and Conscientious

Customer Portal

New Customer Registration Form

Your Personal User Information

Location Information