Become A Provider

This is a private, provider-only platform. Pricing and ordering are never displayed publicly and become available only after your application is manually reviewed and approved.

Practice Information

Practice / Clinic Name

Practice Type

Tax ID / EIN

Practice Address

City

State

ZIP Code

Practice Phone

Website

Primary Contact & Credentials

First Name

Last Name

Credential

Direct Phone

NPI Number

State License Number

License State

License Expiration

License Documentation (optional)

PDF or image, up to 8 MB. Stored privately and visible only to Ascendant River staff.

Prescribers

List every prescriber who will order under this account.

Prescriber 1

Full Name

Credential

NPI Number

License Number

License State

License Expiration

Shipping Information

Where approved orders should be delivered.

Ship-To Name

Street Address

Suite / Unit

City

State

ZIP Code

Preferred Carrier

Delivery Instructions

About Your Practice

How did you hear about Ascendant River?

Product categories of interest

Anything else we should know?

I attest that I am a licensed healthcare professional and that the credentials provided above are accurate and current. I agree that any pricing, documentation, and materials made available through the Ascendant River provider portal are confidential and for professional use only.

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