I confirm that the information submitted in this form is accurate and authorized
*
I confirm that the information submitted in this form is accurate and authorized.
First Name
*
Last Name
Email Address
*
Phone Number
*
Company Name
*
Website
*
EIN (Employer Identification Number)
*
NPI Number
*
Email address of the NPI holder
*
Yes
No
Do you have a reseller’s permit?
*
Yes
No
Reseller Permit Number
*
Upload Reseller Permit Certificate
*
Upload Reseller Permit Certificate
The physician whose NPI is being used must send the authorization email
*
I understand that the physician whose NPI is being used must send the authorization email to
[email protected]
, CC'ing
[email protected]
and the email address used to create this account, to complete this process.
Address
Address Line
*
City
*
State
ZIP Code
*
