SIGN UP NOW! Company Facility Information: Email Address: * UserName: DEA Number: * DEA Exp. Date: * Are you a 340B Entity? Yes No Facility Name: Address: City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY ON Zip: First Name: Last Name: Phone: Fax Number: State License #: State Lic. Exp. Date: Class of Trade: Ambulance Service Ambulatory Care Center Behavioral Health - Inpatient Behavioral Health - Outpatient Chain Children's Medical Clinic Clinical Research Organization Closed Door Pharmacy Community Health Center Consumer Contract Pharmacy Critical Access Dental Dialysis Center Distributor Doctor First Responder Freestanding Healthcare Lab General Medical and Surgical Home Infusion Hospice Hospital Independent Pharmacy Law Enforcement Long Term Care Mail Order Pharmacy Manufacturer Maternity Hospital Oncology Orthopedic Hospital Physician Prison/Correctional Health Psych/Mental Health Hospital Public Health Department Rehabilitation Center Retail Pharmacy Retail Pharmacy Operations -Select COT- Substance Abuse Treatment Ctr Surgery Center Veterinarian Wholesaler State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY ON Bill/Issue Credit To Information: Address: * City: * State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY ON Zip: * Shipping Information: Address: * City: * Zip: * Wholesaler Information: Wholesaler: * MWI Veterinary Supply Company Patterson Logistics Services, Inc Henry Schein Bell Medical PureWay Total Compliance AmeriSource Corporation Cardinal Health H.D. Smith Wholesale Drug Company McKesson Pharmaceutical Southern Anesthesia And Surgical Bound Tree Medical, LLC McKesson Medical-Surgical/PSS Moore Medical Life-Assist, Inc. Midwest Veterinary Supply Other None Account #: Address: City: State: AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY ON Zip: