Dermatology Clinic Registration | Apply for Wholesale Access

Register

Register your clinic or pharmacy to access FDA-approved dermatology products, wholesale pricing, and fast, reliable distribution through DermaDistributor.

Download Payment Authorization Form

For secure and seamless transactions, please download and complete our Payment Authorization Form.
Once filled and signed, kindly email it to info@americanapd.com
to complete your account setup or process your payment authorization.

Download the Form

Send it on : info@americanapd.com

Information Code (T

Business Type

DBA Name

Company Name

GLN Number

Shipping Information

Shipping Address

Shipping Suite

City

Checkboxes

Billing Information same as Shipping Information

State

ZIP Code

Billing Information

Billing Address

Billing Suite

City

State

ZIP Code

Contact Information

Phone

Fax

Ownership Information

Owner Name

Second Owner Name

NPI Number

Phone

State Licenses Number

DEA Licenses Number

DEA License Upload

Proof of Address (ie. Waterbill, Energy bill with Business name)

PIC Pharmacist License

Agreements

Checkbox (T & C)

I agree to the Terms and Conditions

Last updated: 2025-06-23

Checkbox

I consent to receive SMS messages. Msg & data rates may apply.

Electronic Signature Consent

Clear Signature

By signing below, I affirm that I have reviewed and agree to the Compliance & Terms and Conditions (version 2025-06-20), consent to use an electronic signature, and acknowledge it is legally binding under ESIGN/UETA.

Signature Date

Registrations are currently disabled.

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Download Payment Authorization Form

Download the Form

Shipping Information

Billing Information

Contact Information

Ownership Information

Agreements

Derma Distributors

Company

Support & Resources

Social Media

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