Become a Provider | Hillstone Pharmacy

Provider Application

New Account Setup Packcage

Thank you for choosing Hillstone Pharmacy! We are committed to providing high-quality pharmacy services to support your practice.

Please review your entries. You do not need to click through each field. Simply review the document and click on the signature fields below.

Practice Demographics

Practice Name *

Practice Email *

Practice Phone Number *

FAX *

Practice Physical Address *

State *

City *

ZIP *

Practice Type (select all that apply)

Physical location where patients are seen

Telemedicine Only

Hybrid (in-person and telemedicine patient care)

Office Contacts

Contact Person Name *

Contact Number *

Contact Role *

Practitioner Demographics

Practitioner Name *

License Type *

Provider NPI Number *

State CS License / Registration # *

Surescripts SPI # *

State DEA # *

Are you registered in other states?

Licensed State *

State License Number *

DEA (if applicable) *

Billing Information (Optional)

For any customers that do not feel comfortable, providing their credit card detail in this form, please reach out to 865-909-9713. Before calling, please submit your completed form, then give us a call. Thank you for choosing Hillstone Pharmacy! We are committed to providing high-quality pharmacy services to support your practice.

Cardholder Name

Billing Address

State

City

ZIP

Phone Number

FAX

Payment Options (select one)

VISA

MASTERCARD

DISCOVER

AMEX

Card Number

Expiration Date

CVV

Contact Name

Contact Number

Contact Email

Credit Card Authorization Agreement (Optional)

Cardholder Name

Date

I agree and authorize Hillstone Pharmacy to charge my credit card as outlined.

Authorized Agents (Optional)

Name

Title

Email

Privileges (select one)

Full Privileges (submit RX, view status)

Limited Privileges (view only)

Mid-Level Practitioner Acknowledgement

MLP Practitioner Name *

Practitioner Email *

State Medical License # *

State Licensed *

Do you have a collaborative agreement? *

Yes

No

Do you have independent authority? *

Yes

No

Are you permitted to prescribe compounded medication? *

Yes

No

Does your collaborative agreement permit this? *

Yes

No

Telemedicine Only Compliance: *

Yes

No

Collaborating / Supervising Practitioner Info

Supervising Physician Name *

Supervising Physician Email *

Professional Designation *

DEA # *

Provider NPI # *

State CS License / Reg # *

Address under State Medical License *

State *

City *

ZIP *

Date *

Policy Acknowledgment

Practitioner Name *

Date *

I agree and understand the terms outlined above.

Please allow a minimum of 48 hours for your request to be processed.

You will receive a text notification as soon as your medication is ready for pick-up or has shipped.

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