Medically Integrated Dispensary/Pharmacy Enrollment Form

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Medically Integrated Dispensary/Pharmacy Name *

Dispensary/Pharmacy NCPDP *

Medially Integrated Dispensary/Pharmacy NPI *

Dispensary/Pharmacy Street Address *

Dispensary/Pharmacy City *

Dispensary State *

Medical Dispensary/Pharmacy Zip Code *

Primary Contact Name *

Primary Contact Phone Number *

Primary Contact Email *

Is this an independent pharmacy or dispensary? Please explain ownership structure. *

Dispensary/Pharmacy Bank Routing Number *

Pharmacy/Dispensing Bank Account Number *

Acknowledgement: We see immunology patients, and will submit applications for those patient fills *

True

False

Submit

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