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| Account No |
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| Account Mgr |
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Primary Contact Info |
| Company* |
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| Contact* |
First
Last
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| Title |
(DMD, DDS, MD, RN, etc. 20 chars max)
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| Phone* |
(###-###-####)
Ext |
| Fax* |
(###-###-####)
No Fax 
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| Email* |
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| Tax ID* |
(Tax ID or SSN) |
| Payment |
(Additional payment information can be provided later)
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Additional Contacts
If there are staff members who should be contacted for specific tasks, please enter them here.
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Enter Other Contacts |
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Shipping Info |
| Address* |
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NOTE: Please enter your suite number in the field above. |
| Address 2 |
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| City* |
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| State* |
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| Zip Code* |
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Billing Info |
| Use Shipping |
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| Address* |
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NOTE: Please enter your suite number in the field above. |
| Address 2 |
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| City* |
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| State* |
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| Zip Code* |
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DEA Certificate |
| No DEA |
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| Number* |
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| Expires* |
(mm/dd/yyyy) |
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DEA Certificate name as it appears on the Certificate |
| Name* |
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State License |
| Number* |
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| Expires* |
(mm/dd/yyyy) |
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State License name as it appears on the License |
| Name* |
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Primary Practice
Please indicate your primary practice type. We may use this to better tailor your experience on the website.
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Website Passwords
Select a master password for access to both the MPS and CodeBlue websites.
This password gives you full access to formulary management, online ordering, package tracking, statements, purchase history,
and the CodeBlue Monitoring Service website.
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| Password |
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| Confirm |
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| Select a limited access password for just the CodeBlue Monitoring Service website. This can be used to give access to staff members who maintain your crash cart inventory. |
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| Password |
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| Confirm |
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How did you hear about Medical Purchasing Solutions? |
| Source |
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| Referral Type |
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Internal Notes |
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Documents
Copies of your DEA Certificate and State License may be faxed to (800) 351-0834, Emailed, or uploaded.
We will need this information to finalize the account.
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Create AMP Account
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