Provider Access Application

Apply for verified provider access to obtain institutional-level account credentials and authorized pricing for research-grade materials. Complete the form below to initiate your account verification process with Alpha BioMed Labs.

Disclaimer: Alpha BioMed Labs provides platform access exclusively to verified healthcare providers, research institutions, and group purchasing organizations (GPOs) for institutional and laboratory use. All product orders must originate from authorized accounts and are supplied strictly for in-vitro research and analytical purposes. Alpha BioMed Labs does not sell directly to patients or individual consumers, and all materials are distributed under research-use-only (RUO) classification.

Provider Account Request

Contact Information

Name *

Suffix

Email *

Phone *

Business Profile

Company Name *

Business Type

Website *

Tax ID / EIN *

NPI Number *

State License Number (optional)

Does the owner of the NPI number match the contact for this account?

Yes

DEA Registration Number (optional)

Does your business have a reseller's license *

Yes

Helps determine your eligibility for sales tax exemption.

Reseller's Permit Number *

Business Address

If not applicable, use your main operating address. All fields are required.

Address *

Address line 2

City *

State *

ZIP / Postal Code *

Verification & Referral

Optional at this stage. Clinics may upload a business permit; individual providers may upload a license or valid ID. Documents are requested by our verification team later to complete your application.

Referred by someone? Let us know! *

Additional Notes

Comments

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