OPA Independent Pharmacy Special Interest Group Application

Enroll today for a better tomorrow!
First Name
Middle Name
Last Name

Pharmacy's Information:

Pharmacy's Name:
Pharmacy Address
Pharmacy City State Zip
Email
Phone Fax
Primary Wholesaler
Wholesaler Acct #

Dues Rate:

Please select one from the drop-down:
Dues Rate:
All billing is done through your primary wholesaler (who you designate at the time of enrollment) on a monthly basis and may be tax deductible to you as a business expense.
Questions?
Contact OPA at 614.586.1497, email us at opa@ohiopharmacists.org or visit us online at
www.ohiopharmacists.org/sig.html.
   - denotes required fields