You will need to provide the following information during the enrollment process:

• First name, last name, gender, date of birth, social security number, and place of birth
• Taxonomy and Primary Taxonomy – list one or more specialties that you practice
• Provider name, address, and ZIP code of the mailing, billing, primary service location, as well as secondary service location address if applicable.
• Owners and/or Key Personnel must have first name, last name, gender, date of birth, social security number, and place of birth
• National provider identifier (NPI) and tax ID (FEIN)
• License, CLIA, DEA or any license or certification information
• If a pay-to provider, financial information and a filled out W-9 will need prepared
• Pharmacy providers will be required to fill out a Trading Partner Agreement