If you choose "Save and finish later", we will send an email to the "Owner Email" address on the first tab below which will allow you to return to the form.
This icon denotes information that may be common across all stores. Clicking it will copy the value entered on the first tab to the respective field on this tab.
Pharmacy Legal Name
Pharmacy Name (DBA)
Pharmacy Address
City, State Zip
Owner name(s) – if multiple owners, what is the ownership % of each owner?
Owner Phone Number (Best number to reach you)
Owner Email (Personal)
Absentee Ownership
Building Type
Other Building Type Details
Hours of Operation
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
What % of prescriptions filled are narcotics
Percent of business Rx/OTC
Approximate store inventory
Rx:
Front end:
Annual Sales Volume
Annual Script Count
Any pending PBM audits
PBM Audit Details
Are licenses in good standing with DEA/BOP?
License standing details
# Pharmacists (FT/PT):
# Techs (FT/PT):
# Clerks (FT/PT):
# Drivers (FT/PT):
Other
Niche business and % of volume:
(CTRL+Click to select multiple)
Other Niche Details?
What type of LTC?
Do contracts exist?
Do you have mail order contracts?:
Who do you hold mail order contracts with?
Are you a 340b contracted pharmacy?:
What percent of business is 340b?
Accreditations/Certifications:
Accreditations/Certification Details
Does the pharmacy deliver?
Does the pharmacy own the vehicle?:
Number of vehicles owned
What percent of deliveries?
Name of pharmacy system / POS
Other pharmacy system
Size of the pharmacy (square footage)
Do you own the building?
Do you plan to sell or lease?
Approximate value of building
Monthly lease amount
Expiration of current lease?
Is there an option to renew lease?
Monthly rent amount
Year pharmacy established
Year of current ownership
Primary Wholesaler
Other wholesaler
Primary PSAO
Other PSAO
Do owner(s) want to continue working
Continue working - Other comments:
Are you willing to consider seller financing?
Percent of the total purchase price willing to finance