*In this email you will receive the registration confirmation
*The password must be at least eight (8) characters long, combine uppercase and lowercase letters, and contain at least one number or symbol.
Employee First Name
Employee Last Name
User Job Position
Are you an independent pharmacy?
Are you a Pharmacy Services Administration Organization?
Are you a Chain?
Tax ID Number
What is your registered company name?
Have you received payments from us before?
Do you receive electronic payments?
What is the registered bank account?
What is the last check number received?
Please provide at least three (3) chain codes for your organization:
What is the NPI?
What is the contact Person and/or e-mail according to NCPDP?
Please provide your policy number
What entity is providing your policy number?
What is your coverage amount min/max under your policy?
What are the effective dates for your policy?
Please provide one of your DEA or State License with effective dates.