Registration | Hikma Community Health

* All fields required

Sold-to account number *

Ship Tos I want Access to

All existing Facilities

Facility Name *

Street Address *

Street Address 2

City *

State *

Zip *

Add an additional Ship To location

Remove additional Ship To location

Facility Name *

Street Address *

Street Address 2

City *

State *

Zip *

Add an additional Ship To location

Create Password *

Confirm Password *

* All fields required

Facility Phone Number *

Email address to receive order confirmation *

I do not know my Hikma Account Manager

Name on Letter of Authorization

License Number of person

Upload Applicable State license & DEA registration
here

Click to Browse or Drag & Drop document files here

GPO Affiliation (MMCAP)

* All fields required

I do not have a DUNS Number

Requested Credit Limit

Do you accept the Terms and Conditions for Credit? *
Yes
No

Bank & Trade References

Click to Browse or Drag & Drop document files here

Accounts Payable Email *

Paperless invoicing Question: *

For Email invoices please provide email address: *

Please drag and drop any required files you have related to invoicing (EDI instructions, portal information, etc.)

Click to Browse or Drag & Drop document files here

All distributers of controlled substances are required by the United States Drug Enforcement Administration (DEA) to "know our customers" per the Controlled Substances Act and 21 CFR 1301.74 (b)). In response to the DEA requirements, Hikma Pharmaceuticals USA Inc. (Hikma) has implemented a Due Diligence Program to "know our customers."

Completion of the questionnaire is required to purchase controlled substances.

The questionnaire should be completed in its entirety and signed by the responsible party who holds the DEA registration or by power of attorney as authority to sign for that DEA registration.

Please provide the appropriate individual's contact information below. The questionnaire will be sent via email in 24-48 hours.

* All fields required

You will receive an email shortly confirming receipt of your submission. Hikma Community Health Customer Service will contact you once your account has been finalized.

In the meantime should you have any questions please do not hesitate to reach out to your account manager or our Customer Service Team:

* All fields required

Sold-to account number *

I do not have a sold-to account number

DEA Registration Number *

* All fields required

Sold-to account number

Sold To Account Name *

First Name *

Last Name *

Job Title *

Facility Name *

Street Address *

City *

State *

Zip *

Phone *

Email address to receive order confirmation *

Email Address to receive invoices

Authorized Signers *

Name on Letter of Authorization

Title of person

License Number of person

Facility DEA Number *

My facility does not have a DEA registration

Upload Applicable State license & DEA registration here

Click to Browse or Drag & Drop document files here

Letter of Authorization Template

Back

Completion of the questionnaire is required to purchase controlled substances.

The questionnaire should be completed in its entirety and signed by the responsible party who holds the DEA registration or by power of attorney as authority to sign for that DEA registration.

Please provide the appropriate individual's contact information below. The questionnaire will be sent via email in 24-48 hours.

* All fields required

First Name *

Last Name *

Job Title *

Phone *

Email *

Back

Remove additional Ship To location

Facility Name *

Street Address *

City *

State *

Zip *

Facility Phone Number *

Email address to receive order confirmation *

Authorized Signers *

Account Manager *

I do not know my Hikma Account Manager

Facility DEA Number

Upload Applicable State license & DEA registration
here

Click to Browse or Drag & Drop document files here

Add an additional Ship To location