Merchant Registration

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Attention Healthcare Providers,

We provide discounted pricing 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

Professional License, Certification, and/or Re-Seller's License:

Upload your professional license, certification, and/or re-seller's license below. 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

Max. file size: 1,000 MB.

California Sales Tax Exemption

Please attach your sales tax exemption certificate if applicable. Please note that if you do not include a sales tax exemption certificate, you will be charged sales tax on all orders shipping to California.

Drop files here or

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

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Password*

Confirm Password*

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Comments

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