Provider Application

2 Ordering & Communications

Primary Order Contact *

Primary Order Email *

Notifications only — order confirmations, product updates, and price changes are sent here. This address is not a portal login.

How did you hear about American Wellness Pharmacy? *

3 Authorized Agents (CSA) (optional)

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).

Optional — leave blank if no one other than the provider will place orders. If you do add an agent, an email is required (a login is created for them when the application is approved).

Who can do what once approved:

Prescriber (Section 4) — logs in, submits prescriptions under their own NPI, and manages the clinic's users.
Authorized agent — "Can place orders" — gets their own login and may submit prescriptions on the prescriber's behalf, effective immediately on approval. The prescriber can revoke this anytime under Account Settings → Authorized Users.
"View only" — gets a login to see orders and the catalog, but cannot submit prescriptions.

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. This account becomes the clinic administrator: it prescribes under its own NPI, and can add other providers, staff, and authorized users later.

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.

Our team will review and respond within 1–2 business days.

1 Clinic Account