Pharmacy Group of New England	P.O. Box 1450 127 Pleasant Hill Rd., Scarborough, ME 04074 Tel# 800.639.1609 Fax# 207.396.5326 E-Mail pgne@pgnerx.com
Enrollment entitles the member store to participate in any or all contracts negotiated on their behalf by the Pharmacy Group of New England (PGNE)
PHARMACY NAME:_______________________________________________ CONTACT NAME:________________________________________________ TITLE  :_______________________________________________________ STREET  ADDRESS:______________________________________________ MAILING   ADDRESS (If Different): ____________________________________
CITY:_____________________________    STATE:________  ZIP:________
TELEPHONE:________________________   FAX #:____________________
DEA #:_______________________NABP #:__________________________
STATE LIC #____________________ FEDERAL TAX ID #:________________
WHOLESALER:_______________________ ACCOUNT #:________________
ACKNOWLEDGEMENT OF BUYING GROUP
As a contracted member of the Pharmacy Group of New England (hereafter referred to as PGNE) I hereby acknowledge PGNE as the only buying group that I will allow my wholesaler to release history reports for specific contracted vendors that require such information. This does not allow release of my complete sales history. This authorization is effective as of the date below and will continue in effect until you are otherwise notified by the undersigned in writing.
Signature:_______________________________ Date:_________________ Name:________________________________________________________ Fax to: 207-396-5326