PSMA Connect Member Enrollment

PSMA Connect Member Enrollment

Enrollment

Email (Username)

Password

Confirm Password

First Name

Last Name

Title

Practice Name

Address Line1

Address Line2

City / Town

State

ZIP Code

Phone

Physician Count

Federal Tax ID

Medical Supply Dist.

Distributor Acct(s) #

Distributor Rep.

DEA#

HIN#

Specialty

By clicking submit, you are agreeing and digitally signing to the terms of the Participation Agreement