Pharmacy Registration

Pharmacy Details

Pharmacy NCPDP#*

Pharmacy NPI#*

DEA#*

Verify your DEA Number#*

Pharmacy State License#*

Federal Tax ID#

Pharmacy legal Name/ DBA*

Store#*

Phone#*

Mobile Phone#*

Fax#*

Web Site Link

Physical Address

Physical Address*

City*

State*

Zip Code*

My Physical and Mailing Address is Same

Mailing Address

Mailing Address*

City*

State*

Zip Code*

Other Details

Pharmacy Manager (PIC)/Contact Name*

Contract Manager*

E-mail Address*

Password*

Confirm Password*

Password did not match.

FIRST NAME*

LAST NAME*

ADDRESS ONE*

ADDRESS TWO

EMAIL ADDRESS*

CITY*

STATE*

ZIP*

Account Type *

Account Number *

Routing Number *

Name On Account *

Bank Name *

eCheck Type *

Review the following statements:

Has the owner or pharmacy ever had a DEA registration suspended or revoked ?

Yes No

Does the pharmacy solicit buyers or orders of controlled substance via internet or offer to facilitate the acquisition of a prescription for a controlled substances from a practitioner with whom the buyer has no Pre-existing relationship via online questionnaire without a medical examination or bona-fide doctor-patient relationship ?

Yes No

Is your clinic or pharmacy affiliated with another pharmacy?

Yes No

Are one or more practitioners writing a disproportionate share of the prescriptions for controlled substances being filled by the pharmacy?

Yes No

Does the pharmacy offer to sell controlled substances without a prescription?

Yes No

Any exceptions/circumstances where the pharmacy doesn't follow procedures to verify prescriptions and validate bona-fide doctor patient relationship?

Yes No

Any exceptions/circumstances where the polices and procedures set by the pharmacy/clinic to prevent the diversion of any medication by staff employees /patients/other are not use?

Yes No

Does the pharmacy/clinic fill prescriptions for patients who are not domiciled in the state they are located in?

Yes No

Have any corporate officer/owner/pharmacist of the pharmacy ever been charged,convicted,plead no contest or had adjudication withheld on any charge involving possession , use or distributions of controlled substances under the federal controlled substance act or any state laws pertaining to controlled substances?

Yes No

Sterile compounding

Yes No

Non Sterile compounding

Yes No

Agree to follow all federal and state regulations including Drug Supply Chain Security Act (DSCSA).

Yes No

RX Company requires a copy of valid pharmacy state license permit and DEA prior to final approval.

Yes No

Check this checkbox if you agree to the terms and conditions above.

Date*

I agree to

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