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Company/Shipping Info
Contact Us
Please Call Beck-Lee to have your account information setup & obtain a customer account number at 800-235-2852. Or fill out the New Customer Application Form below and submit.

New Customer Application Form
* Required fields

*Account Name
*Medical Specialty
Address 2
Suite No.
*State *Zip:
*Fax Number
*Buyers (first name only)
Email Address
DEA Registration No.
DEA Expiration Date
State License Number
Please be certain that we have a copy of your D.E.A. License for verification. D.E.A. controlled drugs cannot be shipped without verification and can only be shipped to the address shown on the D.E.A. License

Terms Requested:
Bill Me Credit Card

Credit Card Type:
American Express

Credit Card Number

Expiration Date


Shipping Information:
Same as Above Ship to Address Below

Shipping Via:
UPS Ground US Priority Mail
Special Instructions

Your request will be processed immediately.

Phone 1-800-269-4568
Fax 1-800-525-4568