Contact Information

First Name *

Last Name *

Suffix

Email *

Phone *

Business Profile

Business Name *

Business Type *

Website *

Tax ID / EIN *

NPI Number *

Does your business have a reseller’s license *

Yes

Not Sure

Helps determine your eligibility for sales tax exemption.

Reseller’s Permit Number *

Upload Reseller’s Certificate *

Business Address

If not applicable, use your main operating address

Address *

Street Address

City

State

Country

Postal code

Verification & Referral

Upload Proof of Business or Professional License

Optional at this stage. Clinics may upload a business permit; individual providers may upload a license or valid ID. Required later to complete your application.

Referred by someone? Let us know!

Optional—but filling this in may give you priority approval if applicable!

Additional Notes

Comments

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