Healthcare Professional Application Sales Rep:Medical Group Name:Primary Address:City:State:Zipcode:Office Phone Number:Website: Tax ID# (EIN):Lead Physician Name:State Medical Lic #Mobile Number:NPI #Email Address: Number of Practitioners in Group:Site Administrator:Mobile Number:Email Address Medical Specialty: Internal/General Medicine Pain Managment Rheumatology Oncology Neurology Podiatrist Homeopathic Chiropractor Pharmacy Dentist Physical Therapist/Sports Med Multiple Specialties - Please list: Healthcare Network Distributor of Healthcare Products Number of Locations:Do you issue Medical Marijuana recommendations? Yes No Will you be selling CBD in more than one location? If yes, Please list locations.Have you ever sold CBD products? Yes No (if Yes, what CBD products do you currently sell)If you distribute CBD products, what are your monthly average in CBD sales? This iframe contains the logic required to handle Ajax powered Gravity Forms.