Application Form

Join CPPG

Interested in joining CPPG? Fill out the application below and we will be in touch with you shortly.

Your information is entirely confidential and will never be shared with any vendors or third party companies. We respect your privacy and are privileged to offer you our services.

Application

First Name
Last Name
National Provider ID
Title
Email
Phone
Address
Street Address Line 1
 
Street Address Line 2
 
City
State
Zip
Group/ Practice Name
Specialty
Practice Web address
Practice Tax ID
How many doctors are in your practice?
Hospital Affiliations
Office Manager name
Is Office Manager address same as above:
Address
Street Address Line 1
 
Street Address Line 2
 
City
State
Zip
Office Manager Phone Number
Who is your current office supply vendor?
Other:
Are you insured by CAP/MPT for malpractice insurance?
Will you be accessing CPPG’s McKesson Medical-Surgical purchasing program for your medical supplies?
What is your McKesson account number?

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