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

To speak with a compounding pharmacist, please call us on 1-844-857-5588 between 9:30-6:30 EST Monday-Friday or email info@vlspharmacy.com.

Shipping Information