Billing Information
*
Hospital Name / Charge to Name:
Customer DEA # (if applicable):
SBP License # (if applicable):
Hospital 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:
Shipping Information
Check this box if the shipping information is the same as the billing information
*
Hospital Name:
*
Customer DEA #:
*
SBP License #:
*
Hospital 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:
By clicking next, you agree that Medicure may contact you by phone or e-mail to discuss the details of your order. Your contact information may be used to send information about other products and services which may be relevant to you. Please see our Privacy Policy for further details.
Medicure Inc.
Stock
MedicureDirect
Home
|
About
Corporate Leadership
Board of Directors
Careers
Compliance
Corporate Compliance
Colorado Disclosures
|
Products
Aggrastat® (tirofiban hydrochloride) Injection
Aggrastat Patents
Zypitamag™ (pitavastatin) tablets
Sodium Nitroprusside Injection
In Development
Business Development
Generic Products
Tardoxal™
|
Investors
Corporate Governance
Investor News
|
Events
|
Contact
