Request an Independence Medical Account

Independence Medical is a wholesale distributor to businesses such as pharmacies, DME companies and other wholesalers. If you are seeking products for personal use, please consult your local pharmacy or medical supply dealer.

Please provide the following information, and an Independence Medical Representative will contact you to set up an account.

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*Organization:
* Contact Name:
*Business Phone: Ext.
Fax:
*E-Mail:
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