form-clinic - The Chemist Pharm

Provider Information

First Name *

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Last Name *

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Credentials / Title *

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NPI Number *

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License State *

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Email Address *

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Phone Number *

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Practice Information

Practice / Clinic Name *

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Street Address *

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City *

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State *

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ZIP Code *

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Specialty *

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Prescribing Needs

Compound Types of Interest *

HRT / Hormone Replacement Pain Management Dermatology & Skincare Weight Management Thyroid Support Pediatric Formulations Mental Health / Psych Veterinary Compounds

Please select at least one compound type.

Estimated Monthly Prescription Volume *

< 25 Rxs 25–50 50–100 100+

Currently working with a compounding pharmacy?

Yes No

Anything else you'd like us to know?

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Application Submitted!

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Clinic Partnership Application

Provider Information

Practice Information

Prescribing Needs