PSMA Connect Member Enrollment

Email (Username)

Password

Confirm Password

First Name

Last Name

Title

Practice/Company Information:

Practice Name

Address Line1

Address Line2

City / Town

State

ZIP Code

Phone

Physician Count

Federal Tax ID

Specialty

Number of Locations Associated with Practice

Medical Distributor Information:

Medical Supply Dist.

Distributor Acct(s) #

Distributor Rep.

DEA or HIN for RX Pricing:

DEA#

HIN#

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