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.

"*" indicates required fields

Name*

First Last

Clinic Name*

Clinic Address*

Street Address Address Line 2 City State ZIP Code

Email*

Phone*

NPI*

DEA Number*

Comments

This field is for validation purposes and should be left unchanged.