Pharmacy Enrollment Application  

Instructions:

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

Part 1 - Pharmacy Enrollment Application
Part 2 - Services Form

Part 3 - Authorization Form

 
STATUS: APPLICATION DATE:
ENROLLMENT FEE: ANTICIPATING OPENING DATE:
PHARMACY ADDRESS
Pharmacy Name (DBA)
Corporate Name
Street Address
City State   Zip County
Phone   Fax Store email
Mailing Address
(If different above)
City State   Zip  
Single Pharmacy? Multiple Pharmacies?
If Multiple Pharmacies, please name Corporate location.
Yes No Yes No
CONTACT INFORMATION
Contact
Contact Email
Store Website
Preferred
Communication
   
OWNER INFORMATION
Store Owner
Home Address
City State   Zip  
Home Phone
   
PHARMACY INFORMATION
NCPDP #    NPI #
DEA # Expiration Date
EIN # # Pharmacists
Pharmacy License # # Technicians
Store Hours
M-F     SAT     SUN 
   
MEDICAID/MEDICARE INFORMATION
Medicaid #:
Medicare B
Check box if Yes
DMEPOS Accredited?
Accrediting Organization Date
Rx Software Vendor POS Software Vendor
Will you be participating in third party vendor program through NPSC? Yes No
   
VENDOR INFORMATION
Primary Wholesaler
Secondary Wholesaler
Direct Generic Rx Vendor