Dr Cann Pharmacy Registration

For Cannabis Products that Require a Prescription

Shop / Dispensary Registration

English Name *Enter english name of your shop / dispensary

Thai Name (ชื่อไทย)Enter Thai name of your shop / dispensary (Optional)

Contact Name *Enter the person name filling this registration

Position *Position in the organization

Contact Email Address *

Phone *

Company Registration Number *

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code

Country *

Representative / Sales Name Reference (Optional)Name of the representative that recommended your shop/clinic to register.