New Prescriber Account Form

Practice Name
Physician Name
DEA #*
State License #
NPI
Address
Address Suite/Floor City State ZIP / Postal Code Country
Phone
Fax
Office Contact
Alternate Phone
Email*
Shipping Information
Physician Name
Contact person for shipments to be sent to (optional)
Address
Check if the address is same as above
Address Suite/Floor City State ZIP / Postal Code Country
Phone
Email*
Signature required for shipping?
- Yes
- No

New Drug Loft and VLS Pharmacy Licenses

For compounded medications, please call: 1-844-857-5588. For all other matters, please call: 1-844-446-3088.