MFI Medical
MFI Medical Member Enrollment
Login & Contact Information:
Email (Username)
Password
Confirm Password
First Name
Last Name
Title
Practice/Company Information:
Practice Name
Address Line1
Address Line2
City / Town
State
-- Select State --
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
D.C.
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP Code
Phone
Physician Count
Federal Tax ID
Specialty
Medical Distributor Information:
Medical Supply Dist.
Distributor Acct(s) #
Distributor Rep.
DEA or HIN for RX Pricing:
DEA#
By clicking submit, you are agreeing and digitally signing to the terms of the
Participation Agreement