Nationwide Pharmacy Sales

Pharmacy Questionnaire

The data submitted in this form is private and confidential and will only be used by the Twelve31 Advisors | Pharmacy M&A Team

Name

First

Last

Phone

Are you the Pharmacy Owner?

Yes

NCPDP# (Not required, but enables us to respond faster)

Pharmacy Name

Address

City

State/Province

Zip/Postal

Country

When did the Pharmacy Open?

Pharmacy Setting

What are your annual Rx Sales?

# of Total Rx/Month?

# of Retail Delivery Rx/Month?

# of HME/DME Rx/Month?

# of Compounded Rx/Month(Sterile & Non-sterile)?

# of Discounted Generics($4 Rx or similar)/Discounted Cash Rx/Month?

# of Assisted Living Rx/Month?

# of Nursing Home Rx/Month?

# of Hospice Rx/Month?

Please indicate below what percentage of your Rx count is:

Cash%

Medicaid%(State & Managed combined)

Medicare%

Other 3rd Party%

% of controlled substance Rxs?

Do you lease or own the property? If leased, what is your monthly rent and when does the lease expire?

Real Estate Type

Monthly Rent(if Leased)

Lease Term Date

What is the approximate $ amount of pharmacy inventory valued at your acquisition cost?

What is your asking price?

Comments

I Certify that I have permission to report the data in this questionnaire, and that all data is reported accurately to the best of my knowledge

If you are human, leave this field blank.

Sign up for our Newsletter

Nationwide Pharmacy Sales

Pharmacy Questionnaire

Please indicate below what percentage of your Rx count is:

Do you lease or own the property? If leased, what is your monthly rent and when does the lease expire?

READY TO TAKE HTE NEXT STEP?

800-971-3270
Rx@Twelve31Advisors.com

Sign up for our Newsletter

Nationwide Pharmacy Sales

Pharmacy Questionnaire

Please indicate below what percentage of your Rx count is:

Do you lease or own the property? If leased, what is your monthly rent and when does the lease expire?

READY TO TAKE HTE NEXT STEP?

800-971-3270Rx@Twelve31Advisors.com

800-971-3270
Rx@Twelve31Advisors.com