Billing Information
Pharmacy Name
*
Contact Person (Last Name,First Name)
*
Address
*
City
*
State
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Canada - Alberta
Canada - British Columbia
Canada - Manitoba
Canada - New Brunswick
Canada - Newfoundland and Labrador
Canada - Northwest Territories
Canada - Nova Scotia
Canada - Nunavut
Canada - Ontario
Canada - Prince Edward Island
Canada - Quebec
Canada - Saskatchewan
Canada - Yukon
Zip
*
Phone No
*
Alt. Phone No
Fax No
*
Email ID (multiple email should be in comma seperated)
*
NCPDP
*
Card Information
Card Number
*
CVV2/CVC2/CID
*
Expiration Date
*
01
02
03
04
05
06
07
08
09
10
11
12
/
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Card type
*
visa
mastercard
amex
discover
I authorize
Healthlink Solutions (LLC)
to charge the credit card indicated in this web form, for the noted amount on Invoice Send by
Healthlink Solutions (LLC)
. This payment is for
Healthlink Solutions (LLC)
. I understand that returns, refunds and cancellations are
Healthlink Solutions (LLC)
. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company, so long as the transaction corresponds to the terms indicated in this web form.