GPO | Tulsa County Medical Society

Group Purchasing Organization (GPO) Sign-Up

Group Purchasing Organization (GPO) Sign-Up Form

Please complete the following information. All information is needed in order to process your enrollment for this member only benefit. For questions, please contact our office at 918.743.6184 or email mark@tcmsok.org.

Tell us about your clinic, facility and who will place orders

Organization Legal Name

Doing Business As Name

Main Phone number

Purchasing Contact First Name

Purchasing Contact Last Name

Purchasing Contact Phone Number

Purchasing Contact Email

What is the exact shipping address of your facility?

Shipping Address

Suite # (If applicable)

City

State

Zip Code

What type of facility are you?

Pharmacy and/or Suture required?

Name on DEA license

DEA Certificate Number

HIN Location listed w/HIBCC (Should be DBA)

HIN Number

Who will sign your agreement?

Executive Contact Name (Legal Doc Signer)

Executive Contact (Legal Doc Signer) Email

Comment (Please indicate if you have a preferred distributor)

Thank you for completing the GPO sign-up form. This information will be shared with AdvantageTrust and they will follow up with the contact person(s) listed. If you have any questions please contact TCMS at 918.743.6184.

Specialty Societies

Specialty Societies

Group Purchasing Organization (GPO) Sign-Up

Group Purchasing Organization (GPO) Sign-Up Form