Empire Rx — ERXD LLC — NABP Accredited Drug Distributor

New Customer Application

For licensed pharmacies. Complete this application online — you'll receive a PDF copy by email, and our compliance team reviews it within one business day. A copy of licensure must be attached.

Company Information

Contacts

Ship To (Must Match License #)

Max 8MB. This is required — applications without a license copy cannot be reviewed.

Bill To

Webstore Login

Certification

The undersigned principal(s) certify that he/she has full authority to act on behalf of the above-named account ("Applicant") and that all information contained in this application and on each document submitted in connection herewith is true and complete. The Applicant and each undersigned guarantor authorize ERXD LLC ("ERXD") to obtain credit profile information from the national credit bureau(s) for the purpose of considering this credit application and any subsequent update, renewal, collection or additional credit, and authorize each bank and trade reference listed to release information to ERXD. If this application for business credit is denied, you have the right to request a written statement of the specific reasons by mail to ERXD at 63 Montgomery Ave, Staten Island NY 10301 within sixty (60) days of notice; ERXD will respond within thirty (30) days. The Federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants; the administering agency is the Federal Reserve Consumer Help Center, P.O. Box 1200, Minneapolis, MN 55480. The full certification text appears on the PDF copy of this application.

Personal Guaranty (for credit terms)

Usually required for Net payment terms. You can also complete this later with our team.

Terms & Conditions

Please read the Terms & Conditions (opens in a new tab). They also appear in full on the PDF copy of your application.

On submit you'll get an email with the completed PDF, and our compliance team is notified instantly.