Please enter your information below to JOIN NOW. A representative of Buygility will contact you soon with a membership number and start you on your way to savings! About Your IMPACT FaciltyBusiness Name* Business Shipping Address* Street Address Address Line 2 City State ZIP / Postal Code Business Phone*Contact Name* First Last Title/Position* Contact Email* Website Address Please enter N/A if no website.Member Primary Service (Choose one below)*Ambulatory Care/Physician's OfficeAdult Day Care CenterAssisted LivingBehavioral Health - InpatientBehavioral Health - OutpatientCharityCommunity Health CenterCont Care Retire Community (CCRC)DentistryDialysis CenterDME & Supply DealerFirst ResponderFreestanding Healthcare LaboratoryHealth Plan/HMO/PPOHealthcare Corporate OfficeHealthcare Management Svc OrgHome Health Care AgencyHome InfusionHospice – Home CareHospice – InpatientImaging CenterIndependent LivingMail Order PharmacyMeals on WheelsMedical AssociationOncology CenterPharmacyPrison/Correctional HealthPublic Health DepartmentRehabilitation CenterRetail PharmacySkilled NursingStudent/Employee Health SvcSubstance Abuse Treatment CenterSurgery CenterVeterinaryWellness Facility/Fitness CtrHealthcare-OtherAre you purchasing pharmaceuticals?* Yes No Pharmaceutical Distributor Name* Provider DEA#*Enter provider's DEA number associated with the facility's shipping address. If not readily available, enter PENDING. Provider NPI# and/or HIN#If you don't have a NPI# or HIN#, leave blank. If you have one and don't have the number handy, enter PENDING. Your information will be used to populate the necessary forms for membership which include the Buygility GPO Membership form, the Premier Inc. GPO Membership form, and a standard GPO Declaration form (which is sent by us to multiple suppliers to get GPO pricing for you on the items those suppliers sell).Forms will be emailed to you for electronic signature. You should receive an email from DocuSign within a few minutes.NameThis field is for validation purposes and should be left unchanged.