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Medical Purchasing Partners Membership Form

There is no membership fee to join Medical Purchasing Partners.
In order to join Medical Purchasing Partners, you must complete the form below.

If you have any questions while filling out this form, please call us at (914) 232-7945.

Participating Member Name (Facility Name)

Person Completing Form

Use legal name as shown on your income tax return.

First Name

Last Name

Title

Email Address

MPP communicates with practices via email. Please provide us with a valid email address.

List all physicians' names and DEA numbers

Managing Physician

First Name

Last Name

Managing Physician DEA Number

Managing Physician Email Address

Additional Physician 1

First Name

Last Name

Additional Physician 1 - DEA Number

Additional Physician 2

First Name

Last Name

Additional Physician 2 - DEA Number

Year Practice Established

Total Number of Practice Locations

Total Number of Providers

Main Office Location

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Office Telephone Number

(###)

###

####

Office Fax Number

(###)

###

####

2nd Office Location (if applicable)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Office Telephone Number

(###)

###

####

Office Fax Number

(###)

###

####

Office Manager

First Name

Last Name

Office Manager Email Address

Office Manager Telephone Number

(###)

###

####

Purchasing Contact

First Name

Last Name

Purchasing Contact Email Address

Purchasing Contact Telephone Number

(###)

###

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How did you learn about MPP?

I have read and agree to Medical Purchasing Partners' Terms of Use.