Clinic Name * Prescriber Name * NPI# * Contact First Name * Username * Contact Last Name * User Email * User Password * Minimum one uppercase letter, a number, must be 7 characters and no repetitive words or common words Confirm Password * Clinic Address Line 1 * Clinic Address Line 2 City * State * ZIP Code * Clinic Phone * Disclaimer *I understand and agree By submitting this form, you certify that the information provided is true and accurate, that you are a licensed medical provider acting within your lawful scope of practice, and that all compounded medications ordered will be for patient-specific prescriptions only, in compliance with all applicable state and federal regulations governing 503A pharmacies. Clinical decisions, prescribing, and patient care remain solely the responsibility of the authorized provider. A current copy of your active medical license is required and must be submitted for account approval. Duplicate, altered, or expired credentials will not be accepted. Sign Full Contact Name * Submit
