New customer application process
DEA license or HIN certificate
State Board of Pharmacy license
General business and contact information
Payment and credit information
State Sales & Use Tax exemption ID# or certificate
Complete and submit the below form to start the application process.
Prefer to take it slower? Call 866.638.1464, select option 3, and talk to a sales representative.
Payment & Credit Applications
SmartSource offers three payment and credit options. Select the one that works best for your business. Print, sign, scan and email the completed form to SalesAdmin@SmartSourceRx.com. We'll review the form and contact you shortly about your application details. If you'd like help with your application, call 866-638-1464 and select option 3.