SCA New Account Information Form

Before Beginning this form, be sure you have digital copies of the following required documents:

DEA License
State Pharmacy License
CDS License (if applicable)
BNDD License (required for facilities in Missouri and Oklahoma)

For any questions, please contact Customer Service at 877-550-5059 or via e-mail at customerservice@scapharma.com.

Section 1 - Facility Information

Legal Entity

D/b/a

Facility Type

Shipping Address as it appears on DEA License

Address Line 1

Address Line 2

City

State

Zip Code

Pharmacy Main Phone Number

Primary Pharmacy GPO Affiliation

IDN or Health System Affiliation

Section 2 - Licensure Information

State Pharmacy License Number *Not required for VA Hospitals

State License Exp. Date *Not required for VA Hospitals

Upload State Pharmacy license

DEA Number

DEA license Exp. Date

Upload DEA Pharmacy license

Controlled Substance Registration No. (CDS, CSR, BNDD)

Upload CSR Pharmacy license

Section 3 - User Information

Main Contact

First Name

Last Name

Title

Email Address

Direct Phone Number

Authorized CSOS Signer

Communications

Secondary Contact

First Name

Last Name

Title

Email Address

Direct Phone Number

Authorized CSOS Signer

Communications

Additional Pharmacy Contact

First Name

Last Name

Title

Email Address

Direct Phone Number

Authorized CSOS Signer

Communications

Additional Pharmacy Contact

First Name

Last Name

Title

Email Address

Direct Phone Number

Authorized CSOS Signer

Communications

Additional Pharmacy Contact

First Name

Last Name

Title

Email Address

Direct Phone Number

Authorized CSOS Signer

Communications

Additional Pharmacy Contact

First Name

Last Name

Title

Email Address

Direct Phone Number

Authorized CSOS Signer

Communications

Pharmacy Billing Contact

First Name

Last Name

Email Address

Direct Phone Number

Communications

Accounts Payable Contact

First Name

Last Name

Email Address

Direct Phone Number

Communications

ALL INVOICES WILL BE SENT VIA EMAIL UNLESS OTHERWISE SPECIFIED BELOW

Invoicing Method

Additional Information Needed for Billing

Payment Method

Remittance Address:
SCA Pharma ATTN:
Accounts Receivables
PO Box 896546
Charlotte, NC 28289

Section 4 - Terms and Conditions

* I have read and agree to the Terms and Conditions

The person submitting this New Account Information Form agrees the above information is accurate and that they are an authorized signatory for this facility.

E-Signature (Type Your Full Name)

Your Title

Date

SCA New Account Information Form

* To continue a saved form, please click the link which was emailed to you.

Section 1 - Facility Information

Shipping Address as it appears on DEA License

Section 2 - Licensure Information

Section 3 - User Information

Main Contact

Secondary Contact

Additional Pharmacy Contact

Additional Pharmacy Contact

Additional Pharmacy Contact

Additional Pharmacy Contact

Pharmacy Billing Contact

Accounts Payable Contact

Section 4 - Terms and Conditions