Provider Registration – PureDerm Rx

Use this portal to sign up to start prescribing with PureDerm Rx.

Username(Required)

Email (account login)(Required)

Enter Email Confirm Email

Password(Required)

Enter Password Confirm Password

Strength indicator

First Name(Required)

Last Name(Required)

Middle Name

NPI Number(Required)

License State(Required)

License Number(Required)

DEA Number (if applicable)

Only required if controlled substances will be sent via an EPCS-certified e-prescribe system.

Office Address 1(Required)

Office Address 2

City(Required)

State(Required)

Zip(Required)

Phone(Required)

Fax

Prescriber Email (for order records)(Required)