Trading Account Registration

What is the name of your pharmacy (as it is displayed on your external signage)? *

Beneficial Owner / Pharmacy Owner

Pharmacy Address and Eircode

What is your P.S.I. premises registration number? *

What is your pharmacy VAT number? *

Company Registration Number

Supervising Pharmacist

Does your pharmacy have a separate Head Office? *

Yes

Head Office Address and details *

Head Office Contact Name *

Head Office Telephone Number *

Head Office Email Address

If you are human, leave this field blank.