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Account Setup Email Verification Practice Information Business Entity Information Documents Upload Information Verification Authorization and Agreement

Account Setup

Account Administrator

First Name*

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Last Name*

Missing information

Password*

Required

Confirm Password*

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Practice Information

Practice Name*

Required

Specialty*

Required

Email*

Required

Phone*

Required

State Board License #*

Required

DEA #*

Required

NPI*

Required

Practice Address

Street Information*

Required

Suite (if any)

Zip Code*

City*

State*

Practice Manager

Name*

Required

Email*

Required

Phone*

Required

Ext

Required

Accounts Payable Manager

Name*

Required

Email*

Required

Phone*

Required

Ext

Required

Business Entity Information

Legal Entity Name*

Required

DBA*

Required

DUNS*

Required

Federal Tax ID (FEIN) *

Required

Tax Exemption*

Required

Entity Address

Street Information*

Required

Suite (if any)

Zip Code*

City*

State*

Phone*

Required

Owner

Name *

Required

Email*

Required

Phone*

Required

Ext

Required

Documents Upload

State Board License *

DEA License *

Tax Exemption

Information Verification

Practice Name*

Required

Specialty*

Required

Email*

Required

Phone*

Required

State Board License #*

Required

DEA #*

Required

NPI*

Required

Practice Address

Street Information*

Required

Suite (if any)

Zip Code*

City*

State*

Practice Manager

Name*

Required

Email*

Required

Phone*

Required

Ext

Required

Accounts Payable Manager

Name*

Required

Email*

Required

Phone*

Required

Ext

Required

Legal Entity Name*

Required

DBA*

Required

DUNS*

Required

Federal Tax ID (FEIN) *

Required

Tax Exemption*

Required

Entity Address

Street Information*

Required

Suite (if any)

Zip Code*

City*

State*

Phone*

Required

Owner

Name *

Required

Email*

Required

Phone*

Required

Ext

Required

Email Verification

Authorization and Agreement

By signing below the undersigned:

Confirms that all information provided here is true, accurate, and complete.
Agrees to notify the pharmaceutical manufacturer promptly of any changes to the information submitted.
Acknowledges and agrees to abide by all applicable laws and regulations, including compliance with all federal and state laws.
Authorizes the pharmaceutical manufacturer to conduct credit checks, reference checks, and other necessary due diligence to verify the information provided. This includes obtaining financial information and verifying the company’s creditworthiness.
Acknowledges and accepts the terms of this agreement.