Vendxa | Provider Registration

Practice & Facility Information

Complete one registration for each physical location. Required fields are marked *.

Legal Business Name *

Doing Business As (Optional)

Facility / Location Name *

Parent Organization / Health System

Primary Facility Type *

Organization's Approximate Number of Locations

Additional Services Offered (Select all that apply)

Physical Facility Street Address *

City *

State *

ZIP Code *

Facility Phone *

Website

Organization NPI (Type 2), if applicable

Professional Licensing & Documents

Licensing requirements adapt to your facility type. Provide the institution or pharmacy credentials first when applicable; individual practitioner details are requested only where relevant.

Select a facility type in Step 1 to see the appropriate licensing pathway.

Primary Responsible Person / Authorized Contact *

Contact Designation / Role *

Individual NPI (Type 1), if applicable

Professional License Number, if applicable

Professional License Issuing State

Professional License Expiration

Facility / Pharmacy Permit Number, if applicable

Facility Permit Expiration

Will this location seek to purchase controlled substances? *

Regulatory Document Uploads Maximum 5 files

Upload PDF, JPG or PNG documents when available. Missing documents will not prevent registration; Vendxa will follow up. Do not upload patient information, Social Security numbers, or payment credentials.

Document Notes / Additional Licensing Information

Billing, Shipping & Ordering Contacts

One person may fill multiple roles. Use the reuse options to avoid entering information twice.

Primary Registration Contact

Full Name *

Title / Role *

Email *

Phone *

Billing Contact

Same as Primary Registration Contact

Name *

Email *

Phone *

Billing address same as physical facility

Billing Street Address *

Billing City *

Billing State *

Billing ZIP *

Payment & Purchasing Preferences

Preferred Payment Method

Purchase Order Required?

Tax-Exempt Organization?

Accounts Payable Email (Optional)

Shipping Contact

Reuse Contact Details

Name *

Email *

Phone *

Shipping address same as physical facility

Shipping Location Type *

Is Shipping Address the Licensed Practice Location? *

Shipping Instructions (Optional)

Ordering Contact

Reuse Contact Details

Name *

Email *

Phone *

Products & Services

Select your areas of interest. Vendxa will coordinate with the appropriate fulfillment partners.

Products or Services Needed * (Select all that apply)

Specific Products or Services Needed (Optional)

Purchasing Timeframe *

General Purchasing Volume *

Which Vendxa representative referred you or directed you to complete this registration? (Optional)If you do not know, leave this blank. Vendxa leadership will follow up.

Review & Authorization

Review your information before submitting. You can return to any section to make changes.

Required Acknowledgments

I certify that the information provided is accurate and complete to the best of my knowledge, that I am authorized to submit it on behalf of the organization, and that I will provide any outstanding onboarding documentation requested.I authorize Vendxa to securely share relevant business and regulatory information with appropriate fulfillment partners for onboarding and account evaluation.

Submitting this form does not constitute a purchase order or guarantee account approval. Fulfillment partners independently verify licensing and eligibility. Do not submit patient information.

Provider Registration

Practice & Facility Information

Professional Licensing & Documents

Institutional Facility Credentials

Pharmacy / Outsourcing Facility Credentials

Practitioner / Clinic Credentials

Controlled-Substance Credentials

Regulatory Document Uploads Maximum 5 files

Billing, Shipping & Ordering Contacts

Primary Registration Contact

Billing Contact

Payment & Purchasing Preferences

Shipping Contact

Ordering Contact

Products & Services

Review & Authorization

Required Acknowledgments

Registration Successfully Received

What Happens Next?