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HE Co-op New Member Vendor Profile Form
Facility Name
(Required)
Premier Entity Code
(Required)
DEA #
Supply Chain/Purchasing Contact
Name
(Required)
First
Last
Email
(Required)
Phone Number
(Required)
(555) 123-4567
Hidden
Phone
Estimated Annual Spend
Pharmacy Products
(Required)
Medical Supply Products
(Required)
Jan/San
(Required)
Food
(Required)
Pharmacy Wholesaler Information
Primary Pharmacy Wholesaler
Name
Account #
Rep. Name
Rep. Email
Secondary Pharmacy Wholesaler
Name
Account #
Rep. Name
Rep. Email
Medical Supply Distributor Information
Primary
Name
Account #
Rep. Name
Rep. Email
Secondary
Name
Account #
Rep. Name
Rep. Email
Jan/San Distributor Information
Primary
Name
Account #
Rep. Name
Rep. Email
Food Distributor Information
Primary
Name
Account #
Rep. Name
Rep. Email
Vendor Name & Account Numbers
Please attach a full vendor list of current suppliers or itemize below.
File
Max. file size: 50 MB.
Office Supplies
Maintenance/Repair Supplies
Lab Distributor
Cylinder Gases
Purchasing Cards
Credit Card Services
Computer Hardware
Cell Phone Provider
Background Check Services
Staffing
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(Required)
Select One
Nancy
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ABOUT
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Group Purchasing (GPO)
340B Services
Mobile Services
MRI
Iowa Anesthesia
RESOURCES
CAREERS
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