Instructions
In order for MediPharm Labs to setup your organization as a vendor or to change your payment details, we need some information from you.  All payment details will be manually verified with your executive leadership in accordance with our data security policies, prior to implementation.

Security notice: This form is being presented to you through a TLS encrypted web session and the data that you provide will be submitted directly to our customer service team and remain encrypted until processed.  This data is not delivered via e-mail.
Verification Contact Details





Vendor Information















Payment Details
This form is intended to provide banking information only. MediPharm Labs reserves the right to conduct a follow-up communication with a senior company representative to validate information provided. MediPharm Labs is not responsible for any incorrect or fraudulent information provided on this form or the request received on the corresponding company’s letterhead. 





We will not update wire transfer details unless these previous details match what we have one file.

Electronic Funds Transfer Information
Previous Banking Information
To protect against fraud, we will not begin any update to your current banking details unless these previous details match what we have on file.









Banking Information