Customer Signup

    Before begining this form, be sure you have digital copies of the following required documents:

    • DEA License
    • State Pharmacy License
    • CDS License (if applicable)
    • BNDD License (required for facilities in Missouri and Oklahoma)

    For any questions, please contact Customer Service at 480-771-9772 or via e-mail at customerservice@medivanthealth.com

    Section 1 - Facility Information (Shipping)


    Section 2 - Users

    Primary Contact

    Secondary Contact


    Section 3 - Invoicing

    Billing Contact

    ALL INVOICES WILL BE SENT VIA EMAIL UNLESS OTHERWISE SPECIFIED BELOW