City: State: Zipcode:
Is your Medical License in good standing?
Active Medical License:
Is your DEA License in good standing?:
DEA License #:
Malpractice Insurance: Policy#:
This information will be used on the website for patients looking for a Pro-Pell provider in their area as well as for your marketing materials so please make sure the information provided here is complete and correct.
Primary Contact Name:
Practice Business Hours:
Practice Phone # Practice Fax:
Would you like to have a credit card on file with the pharmacy for quick checkout of orders? (If yes, a pharmacist will contact you for the card information after this is received.)
Leave this empty:
If you have questions about the contents of this document, you can email the document owner.
Document Name: Provider's Information
Agree & Sign