Cody Drug Rx
Provider Registration
Clinic
Name
*
Address
*
State
*
Select State
City
*
Zipcode
*
Phone
*
Drug Category
*
Marketer
Select Marketer
Billing email
*
Billing Preference
*
Bill to patient only
Bill to clinic only
Both
Shipping Preference
*
Ship to patient only
Ship to clinic only
In Pharmacy Pick-Up
All
Provider
First Name
*
Middle Name
Last Name
*
NPI
*
DEA #
*
Supervising physician
*
Supervising Physician NPI
*
Portal Clinic Manager User Set-Up
First Name
*
Last Name
*
Email
*
Phone
*
Role
*
Select Role
Security check
*
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