Get started with your enrollment process with AlignRx!
Please complete all sections of this form. If you have any questions, please reach out to our sales team at 1-844-ALIGNRX option 6, or send an email to sales@alignrx.org.
                                                                               
Pharmacy Information
 
NCPDP*:
NPI*:
Tax ID*:
 
Pharmacy DBA Name*:
  Pharmacy Legal Name*:
 
Physical Address*:
City*:
State*:
Zip*:
 
Mailing Address*:
City*:
State*:
Zip*:
 
Phone*:
Fax:
  Pharmacy Email*:
 
Hours of Operation: M-F*:
Sat*:
Sun*:
 
 
Pharmacy Type*:
Ownership Structure*:
 
 
Buying Group Affiliation*:
Primary Wholesaler*:
Secondary Wholesaler(s):
 
Ownership - Include Both Direct and Indirect Ownership; Direct Ownership Percentages Must Add Up to 100%
 
First Owner
 
Owner Name*:
Phone*:
Email*:
 
Address*:
City*:
State*:
Zip*:
 
  Ownership Percent*: %
Direct Owner?*
Second Owner
 
Owner Name: Phone:
Email:
 
Address: City: State: Zip:
 
  Ownership Percent: %
Direct Owner?
Third Owner
 
Owner Name: Phone:
Email:
 
Address: City: State: Zip:
 
  Ownership Percent: %
Direct Owner?
Fourth Owner
 
Owner Name: Phone:
Email:
 
Address: City: State: Zip:
 
  Ownership Percent: %
Direct Owner?
Fifth Owner
 
Owner Name: Phone:
Email:
 
Address: City: State: Zip:
 
  Ownership Percent: %
Direct Owner?
 
Enrollment Contact - This Person Will Be Responsible for Handling All Communication Involving Enrollment
 
First Name*:
Last Name*:
Phone*:
Email*:
 
Authorized Signer - Signer Must Have Execution Permissions for Banking and Contract
 
First Name*:
Last Name*:
Phone*:
Email*: