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Create Pharmacy Account
Pharmacy Name
Email
License Number
Address
Country
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Algeria
Bahrain
Comoros
Djibouti
Egypt
Iraq
Israel
Jordan
Kuwait
Lebanon
Libya
Mauritania
Morocco
Oman
Palestine
Qatar
Saudi Arabia
Somalia
Sudan
Syria
Tunisia
United Arab Emirates
United States
Yemen
State
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City
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National Provider Identifier (NPI)
Telephone
Cell Phone
File Format should be PDF,JPG, JPEG or PNG
License
Default location name
Default location name
Pharmacist
First Name
Middle Name
Last Name
Email
National ID
Association Card Number
Gender
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Male
Female
Date of Birth
Address
Same as Pharmacy
Country
--Select--
Algeria
Bahrain
Comoros
Djibouti
Egypt
Iraq
Israel
Jordan
Kuwait
Lebanon
Libya
Mauritania
Morocco
Oman
Palestine
Qatar
Saudi Arabia
Somalia
Sudan
Syria
Tunisia
United Arab Emirates
United States
Yemen
Telephone
Cell Phone
File Format should be PDF,JPG, JPEG or PNG
Picture ID
File Format should be PDF,JPG, JPEG or PNG
License to Practice
File Format should be PDF,JPG, JPEG or PNG
Association Id Card
Signature
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By submitting this form I approve
MediConfirm Terms and Conditions,
Privacy Policy
and
EULA
I hereby certify, under penalty of perjury, that the foregoing information is true and correct.
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