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Business Support Application

Please provide the following contact information:

*First Name   M.I *Last  
*Work Phone  
*E-mail
*# of Pharmacy Locations  
  * indicates a required field
Pharmacy License #(s)  

How much does it cost?
Independent, Chain, Clinic, Home Care ..... $525 per Wisconsin pharmacy location

Hospitals
 
Less than 100 beds ..... $525
 
100-300 beds ............ $1,050
 
More than 300 beds .... $2,100

Long Term Care ........ $1 per LTC resident served

I am providing my credit card on-line

Please review your information before submitting!

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Email: Dawn Fargen

Pharmacy Society of Wisconsin
701 Heartland Trail - Madison, WI 53717
Telephone: (608) 827-9200 - Fax: (608) 827-9292