Shipping Address Verification : Stem Cell Treatments

McKesson Medical-Surgical Inc. ("McKesson"), as a CSN distributor, and depending on the applicable state law, is permitted to ship regulated pharmaceuticals and medical devices only to authorized recipients. It is McKesson's policy that when a shipping address does not match the address listed on a practitioner's license, the practitioner will be required to verify that the shipping address is a valid practice address for the physician.
Please complete the following form and upload a copy of your license here.
Max. file size: 512 MB.
Name on License:*
First Last
License Number:*
Expiration Date:*
MM slash DD slash YYYY
Type of License:*
Licensing Board:*

(i.e. Board of Medicine, Board of Pharmacy, Department of Health, etc.)
I cerify that I practice at the location(s) listed below and authorize the use of my license in order for McKesson to ship regulated pharmaceuticals and medical devices to the location(s) listed below. (For more than one location, a list of additional authorized locations can be attached.)
Max. file size: 512 MB.
Business Name:*
Business Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Business Telephone Number:*
CSN Affiliate Signature*
Practitioner's Printed Name:*
Date*
MM slash DD slash YYYY
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