Provider Application — American Wellness Pharmacy

1 Clinic Account

Clinic / Practice Name *

Clinic Main Email *

General clinic contact email (not used for portal login)

Clinic Phone Number *

Clinic Website

Clinic Fax Number

Clinic Address *

City *

State *

ZIP Code *

Days of Operation *

Hours of Operation *

2 Ordering & Communications

Primary Order Contact *

Primary Order Email *

Email for receiving product updates, price changes, and order communications from AWP

How did you hear about American Wellness Pharmacy? *

3 Authorized Agents (CSA)

List all individuals given permission and responsibility to order, change, and cancel any prescriptions created by the clinic. The Controlled Substances Act (CSA) defines an "agent" as "an authorized person who acts on behalf of or at the direction of a manufacturer, distributor, or dispenser." 21 U.S.C. §802(3). Under the CSA, the term "dispense" includes "prescribing." 21 U.S.C. §802(10).

Full Name *

Email Address *

Title / Role

Access *

4 Prescriber Information

First Name *

Last Name *

Title / Credentials *

Medical Specialty *

Prescriber Email *

This will be your portal login username

Direct Phone *

Medical License # *

License State *

NPI Number *

DEA Number (if applicable)

Additional Information

5 Billing & Payment

Billing Preference *

Bill Clinic
Clinic is invoiced directly — provide payment info below

Bill Patient Directly
No clinic payment info required

Billing Contact

Billing Contact Name *

Billing Phone *

Billing Email *

Billing Address

Street Address *

City *

State *

ZIP Code *

Credit Card Information

🔒 Security Notice: Your card details are transmitted securely and are only shared with our accounts team for one-time setup. We store only the last 4 digits, card type, and expiration date — your full card number is never stored in our system.

Cardholder Name *

Card Number *

Expiration Date *

CVV *

I authorize American Wellness Pharmacy to charge the credit card above for all compounding services ordered through the AWP Provider Portal. I have read and agree to the Payment Terms of Service. I understand that charges will appear as "American Wellness Pharmacy" on my statement.

6 Agreement

I confirm that all information provided is accurate and that I am a licensed healthcare provider authorized to prescribe medications. I agree to the Terms of Use and Privacy Policy. I understand that submitting this application does not guarantee portal access, and that approval is subject to verification of credentials.