NEW ACCOUNT APPLICATION



 
Shipping Information *Note: Shipping Address must match the Address on the DEA License
 
 
 



 
Billing Information
 
 
 
 
 
 
 



 
Role Information

Please note: only put first and last name in input box for name. Titles are not needed.

 
 
 
 
 
 
 
 
 
 
 

 

"Please email a copy of your DEA and state license to customerservice@cantrelldrug.com