Information Request – Custom RX

Call us at 855-287-6879

Please complete the information below to obtain access to the Custom Rx Pharmacy online portal.

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Patient

Current Custom Rx Prescriber

New Custom Rx Prescriber

Name*

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Email*

Phone

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Clinic Name*

Clinic Address*

Street Address Address Line 2 City State ZIP Code

NPI*

DEA Number*

Phone

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