Become a provider

Thank you for your interest in partnering with GenoGenRx. Fill in your information below to begin your application process via DocuSign.

You’ll need these to complete your application:

  • Practice & License Info: Practice name/address, state license number + expiration, NPI number

  • DEA Info (if applicable): DEA number + expiration, secondary DEA/state, XDEA, Surescripts SPI

  • Contact Details: Office/cell, fax and email.

  • Supervision & Sales Rep Info (if applicable)

  • Payment & Documents: A payment card to keep on file, plus a copy of State Medical License (required) and DEA Certificate (if applicable) to upload

Click to apply

Have questions before applying?

Reach out to our team and we’ll be happy to help.

hello@genogenrx.com

(561)-760-1060