Practice Registration
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Practice Information
Practice Name:
Practice Phone Number:
Practice Address (Primary) Line 1:
Practice Address Line 2:
Practice City:
Practice State:
AL
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CA
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CT
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DC
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HI
ID
IL
IN
IA
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NV
NH
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NM
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OR
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AA
AP
Practice Zip Code:
Practice NPI: (Note: NOT individual prescriber NPI)
Account Admin
First Name:
Last Name:
Phone Number:
Email:
Password:
Password must contain at least 8 characters. At least 1 number, 1 lower case and 1 upper case letter.
Confirm Password:
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