Northeast Pharmacy Service Corporation


. Main

Instructions:
1. Please call the NPSC Office for Enrollment Fee.
2. Fill out this application completely and accurately.
3. Submit to NPSC.

Date:
Pharmacy Name:
Corporate Name: (Sole Proprietorship/Partnership)
Street Address:
City:	State: Zip:
Mailing Address (If different):
Type of Location (Rural, Suburban, City):
Telephone:			..Fax:
DEA #:			..NCPDP#:		NPI#:
Federal Tax ID#:			..State License#:
Medicaid Provider#:			..DME Provider#:
Do you speak a second language?		Yes:		No:
Capable of Electronic Claims Submission?		Yes:		No:
# Pharmacists (FTEs):
# Technicians (FTEs):
# Front Store Employees (Full/Part-Time):
Store Owner:
Home Address:
Home Phone:
Store Contact:
Days & Hours Open:	M-F		SAT		SUN
Special Services:
Primary Wholesaler:
Secondary Wholesaler(s):
Direct Generic Rx Vendor(s):
Managed Care and Third-Party Programs serviced by this location:



Managed Care and Third-Party Programs in your areas which you do not service:



Total Store Annual $ Volume:		$under - $250K
		$250K - $500K
		$500K - $750K
		$750K - $1M
		$1M - $1.5M
		$1.5M - $2M
		$2M - $2.5M
		$2.5M +
# Daily Average Rx's:
# Annual Average Rx's: