Merchant Registration

"*" indicates required fields

Attention Healthcare Providers,

We provide bulk discounts to healthcare providers who are validated by our merchant ordering and authentication system. Please fill out the form below to set-up your merchant account.

First Name*

Last Name*

Phone*

Email*

Company

Website

How did you hear about us?

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

NPI Number*

Referred by

File Upload

Please upload your professional license, certification, and/or re-seller's license.*

*Please note that we are required to collect sales tax on orders in Michigan for those without a re-seller's license. For those in Michigan please include your re-seller's license so that sales tax can be waived for wholesale orders.

Drop files here or

Accepted file types: pdf, jpg, png, jpeg, Max. file size: 1,000 MB.

Username*

Password*

Confirm Password*

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.