List Your Place

This information will let us know more about your place.

Business Information

Business Address

Licenses Information

If your pharmacy does not purchase and dispense controlled substances and does not have a DEA number, please use 000000000 as your DEA number in the field above. You will not be able to search and view controlled substances on Visrex.

Chief Owner

Billing Information

Shipping Information

Controlled Substance Questionnaire


1. What is the percentage of the pharmacy business for the following

A. Source of revenue. Must total 100%.


B. Type of revenue. Must total 100%.

2. What percent of the pharmacy prescription business is controlled substances?

3. What percent of prescriptions for controlled substances come from pain management clinics?

4. How many total prescriptions are filled monthly?

5. Has the owner or pharmacy ever had a DEA registration suspended or revoked?

6. Does the pharmacy solicit buyers or orders of controlled substance via the internet or offer to facilitate the acquisition of a prescription for a controlled substance from a practitioner with whom the buyer has no pre-existing relationship via an online questionnaire without a medical examination or bona-fide doctor-patient relationship?

7. Does your pharmacy or clinic have a website?

8. Is your clinic or pharmacy affiliated with another clinic, pharmacy or healthcare provider?

9. Are one or more practitioners writing a disproportionate share of the prescriptions for controlled substances being filled by the pharmacy?

10. Does the pharmacy offer to sell controlled substances with a prescription?

11. Any exceptions / circumstances where the pharmacy does not follow procedures to verify prescriptions and validate bona-fide doctor-patient relationship?

12. Any exceptions / circumstances where the policies and procedures set by the pharmacy / clinic to prevent the diversion of any medication by staff employees / patients / other are not used?

13. Does the pharmacy / clinic fill prescriptions for patients who are not domiciled in the state they are in?

14. Has any corporate officer / owner / pharmacist of the pharmacy ever been charged, convicted, plead no contest or had adjudication withheld on any charge involving possession, use or distribution of controlled substances under the Federal Controlled Substances Act or any state laws pertaining to controlled substances?

15. List the names of authorized signers of DEA form 222 or holders of CSOS certificates (C.F.R 1205.05)

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Buyer Terms and Agreements

Pharmacy Name:    

, herein referred to as “Pharmacy”.

  1. Usage
    1. Pharmacy completing account set-up understands that the use of this platform is for the purchase of pharmaceutical products and are to be dispensed by a pharmacy entity.
    2. Pharmacy agrees and understands that it is free to sign up but must maintain current and accurate account information.
  2. Compliance
    1. “Pharmacy” agrees to complete all required information upon account set-up.
    2. “Pharmacy” agrees to provide information that includes but not limited to DEA License, State Licenses (State Pharmacy License and State Pharmacy Controlled Substance License) and Tax I.D.
    3. “Pharmacy” agrees to allow electronic notification via Visrex platform as well as email with regards to license expiration dates, information requests, requests from vendors, etc.
  3. Audits
    1. “Pharmacy” agrees to contact and relay to any and all authorized vendors any and all audit requests by any and all third parties with in a timely manner.
  4. Non-Disclosure Agreement
    1. “Confidentiality” as used in this agreement refers to “Confidential Information” that includes but is not limited to any and all information of commercial value, technical information, patent, copyright, trade secrets, proprietary information, models, processes, programs, equipment and services provided by Visrex.
    2. “Confidentiality” as used in this agreement refers to “Confidential Information” in regards to any and all non-technical information that includes but is not limited to products and services provided by Visrex, pricing, margins, strategies, finances, financial information and accounting data, suppliers, customers, customer lists, purchasing data, sales and marketing plans, business plans and development and any other information which is deemed proprietary and confidential to Visrex.
    3. “Pharmacy” agrees to and will maintain in confidence and will not disclose, disseminate or use any and all confidential information belonging to Visrex whether or not in written form.
    4. “Pharmacy” agrees that it shall treat any and all confidential information of Visrex with the same degree of care as it treats its own confidential information.
  5. Non-Solicitation / Non-Compete
    1. During the term that the pharmacy conducts transactions on Visrex and for a period of (5) five years immediately thereafter, “pharmacy” agrees not to solicit any clients, customers, employees, agents and officers of Visrex.
    2. “Pharmacy” shall not directly or indirectly disclose to any person, firm or corporation the names, addresses and or any other information of and/or relating to any customers, clients, trading partners/vendors of Visrex.
    3. Therefore, any and all information pertaining to any and all business conducted by pharmacy on Visrex is to be for the sole purpose of conducting business via Visrex.
    4. “Pharmacy” agrees that during the time it conducts business/transactions on Visrex, it will not directly or indirectly offer same products on Visrex platform to other online pharmaceutical market places at lower prices for the same products and prices posted on Visrex.
    5. “Pharmacy” agrees that form the time of termination of all business/transactions with Visrex.
    6. “Pharmacy” will not solicit any and all pharmacy accounts for a period of (3) three years following termination of business. 
  6. Governing Law
    1. This agreement shall be governed in all respects by the laws of the United States of America and by the laws of the State of Michigan, as such laws are applied when conducting any and all business with an entity formed with in the State of Michigan
  7. Notice of Breach / Injunctive Relief
    1. Visrex must notify pharmacy upon any discovery of any breach of this agreement.
    2. Any actions by pharmacy or its representatives inconsistent with their obligations as set forth by this agreement will constitute a breach of this agreement.
    3. A breach of any section of this agreement will result in irreparable and continuing damage to Visrex.
    4. If there be no adequate remedy by law, Visrex will be entitled to injunctive relief and/or a decree for specific performance and such other relief as may be proper (including monetary damages if appropriate).
  8. Credit Application
    1. Applicant and Personal Guarantor(s) authorize wholesales to obtain credit bureau reports in connection with this request for a credit account. If a credit account is opened, wholesalers may obtain credit bureau reports for both the Applicant and the Personal Guarantor(s) in connection with extensions of credit, the review, or collection of Applicant’s accounts. Wholesalers will review Applicant’s credit history and income to determine if Applicant qualifies for credit and, if so, Applicant’s credit limit. Wholesalers will also review Personal Guarantor’s credit history and income to determine if the Personal Guarantor(s) qualifies as a guarantor of Applicant’s account.
    2. Upon approval of Applicant’s credit line Applicant and Personal Guarantor(s) acknowledge and agree as follows:
      1. Applicant agrees to pay the prices applicable at time of shipment. If a credit line is opened, invoices are due the specified net terms (15, 30 or 45 days) following shipment regardless of date of invoice or date of receipt of invoice or product. The Overdue accounts will bear a finance charge of 1-1/2% per month, or the maximum legally permissible charge, whichever is less.
      2. All persons signing this Application have authority to agree and expressly agree to receive faxes, email and telephone calls from Visrex including, but not limited to, offers, advertisements and similar communications.
      3. On default or failure to pay as agreed, wholesalers may revoke Applicant’s credit line, and Applicant and Personal Guarantor(s) will pay to wholesalers and/or its subsidiaries, affiliates, successors or assigns, all costs and expenses of collection including but not limited to attorney’s fees, assessable costs, and litigation costs and expenses.
    3. In the event Applicant fails to pay any invoice(s) when due, within the stated allotment of time according to the terms of the credit agreement, wholesalers are authorized to initiate debit entries from DEPOSITORY, or charge CREDIT CARD, as indicated below for all amounts due in respect of those invoices and related collection costs and fees.
    4. The terms and conditions set forth herein shall prevail over and supersede any terms and conditions contained in any of Applicant’s purchase orders and/or releases. No change in this Agreement shall be binding unless made in writing and signed by both parties.
    5. This application will not be processed unless the owner or principal of the Applicant signs this Agreement.
    6. By signing this agreement, you acknowledge that you read and understand the provisions described in this agreement.

By signing this agreement, you acknowledge that you read and understand the provisions described in this agreement



Pharmacy Name:    

Pharmacy Owner/Pharmacist In Charge:

(Print Name)

Pharmacy Owner/Pharmacist In Charge:

(Signature)

Date: