Addyi® Direct Buy - Official Site

0624 | Direct Buy

Office Name

NPI Number

Provider Name

Email Address

Phone Number

Contact Name (Of The Person Placing The Order)

Shipping Address:

Is your Billing Address different than your Shipping Address?

Yes

Billing Address:

Is your State Medical License Address different than your Shipping Address?

Yes

State Medical License Address:

I have read and agree to the Addyi direct dispense terms and conditions

By checking this box I acknowledge this Addyi Direct Buy Wholesaler Application (“Application”) does not create a relationship of any kind between applicant and Sprout nor does it create or grant any rights to the applicant by Sprout. This Application is used solely for evaluation purposes and Sprout is entitled, in its sole discretion, to reject any applicant for any reason without providing any feedback or explanation for such decision. Applicant hereby acknowledges and agrees it will not rely on this Application for any form of employment or other relationship with Sprout and will not incur any costs in association with the Application or the application process. Any costs incurred by the applicant are at the applicant's sole expense.

*Download Direct Dispense Terms and Conditions

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