Provider's Information


Provider Information

Full Name:

Cell Phone:

Personal Email:

Home Address:

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#:

Practice Information

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. 

Practice Name:

Practice Specialty:

Primary Contact Name:

Street Address:

City: State: Zipcode:

Practice Business Hours:

Practice Phone # Practice Fax:

Contact Email:

Website:

Payment Terms

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:

Pharmacy Solutions https://rxcompound.com
Signature Certificate
Document name: Provider's Information
Unique Document ID: 3d1ad604054a35a65f79dfcfb3b631bfd9e8ab4c
Timestamp Audit
November 3, 2017 12:24 pm CSTProvider's Information Uploaded by Kim Siegenthaler - Kim@rxcompound.com IP 71.40.239.250
November 3, 2017 12:28 pm CSTKim Siegenthaler - kim@rxcompound.com added by Kim Siegenthaler - Kim@rxcompound.com as a CC'd Recipient Ip: 71.244.26.151
November 3, 2017 12:32 pm CSTKim Siegenthaler - kim@rxcompound.com added by Kim Siegenthaler - Kim@rxcompound.com as a CC'd Recipient Ip: 71.244.26.151
December 20, 2017 10:13 am CSTKim Siegenthaler - kim@rxcompound.com added by Kim Siegenthaler - Kim@rxcompound.com as a CC'd Recipient Ip: 66.169.162.236
December 20, 2017 10:32 am CSTKim Siegenthaler - kim@rxcompound.com added by Kim Siegenthaler - Kim@rxcompound.com as a CC'd Recipient Ip: 66.169.162.236
December 20, 2017 10:36 am CSTKim Siegenthaler - kim@rxcompound.com added by Kim Siegenthaler - Kim@rxcompound.com as a CC'd Recipient Ip: 66.169.162.236
December 20, 2017 6:26 pm CSTKim Siegenthaler - kim@rxcompound.com added by Kim Siegenthaler - Kim@rxcompound.com as a CC'd Recipient Ip: 66.169.162.236
December 20, 2017 6:26 pm CSTPharmacy Solutions - info@rxcompound.com added by Kim Siegenthaler - Kim@rxcompound.com as a CC'd Recipient Ip: 66.169.162.236
January 18, 2018 10:13 am CSTKim Siegenthaler - kim@rxcompound.com added by Kim Siegenthaler - Kim@rxcompound.com as a CC'd Recipient Ip: 71.40.239.250
January 18, 2018 10:13 am CSTPharmacy Solutions - info@rxcompound.com added by Kim Siegenthaler - Kim@rxcompound.com as a CC'd Recipient Ip: 71.40.239.250