My Account

Name: Medicure Inc.
Address: 1250 Waverley Street, Winnipeg, Manitoba, R3T 6C6
Price range: $$

Billing Information

* Institution / Charge to Name:
Customer DEA # (if applicable):	SBP License # (if applicable):
License (if applicable):	* GPO/IDN Affiliation:
* Address Line 1 (will not ship to a PO box):	Address Line 2 (will not ship to a PO box):
* City:	* State:
* Zip Code:	* E-mail:
* Phone:	Fax:

Check this box if the shipping information is the same as the billing information

* Hospital Name:
* Customer DEA #:	* SBP License #:
* License:	* GPO/IDN Affiliation:
* Address Line 1 (will not ship to a PO box):	Address Line 2 (will not ship to a PO box):
* City:	* State:
* Zip Code:	* E-mail:
* Phone:	Fax:

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