Puricorp

Certified Puricorp Provider

To become a Certified Puricorp Provider please fill out the following form so we know that you are a legitimate Provider resource. On the next page you will be able to review the Practitioner Product Program financial information details prior to making your final decision about becoming a part of our Certified Provider Network. You will not be asked to order anything or to provide any credit card or bank information in this process, and you are not ever required to purchase product unless you wish to have product in stock for your clients.

Fields marked with * are required fields

Name of Business*
Primary Practitioner Last Name*
Primary Practitioner First Name*
Title*
Areas of Specialty
Office Phone*
Office Fax*
Street Address*
City*
State*
Postal Code*
Practitioner EIN or License Number
Number of Practitioners in your office/group
I deal with the following addictions
- Alcohol
- Rx Opiate Pain Meds
- Food
- Smoking
If other addictions, please list
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Email*
Password*
Confirm Password*
Permission*
- I hereby grant Puricorp the right to publish my contact name, address, phone number, and type of services for the purpose of client referral from Puricorp to Practitioner. Puricorp assumes no responsibility for level of service or liability of Practitioner or client, this service is provided exclusively as a means of connecting clients with addiction issues to potential resources that may help them.

To be listed as a resource provider and to offer our products:

Certified Puricorp Provider

Create an account