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Pharmacy Enrollment Request
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*:
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Mariana Islands
Marshall Islands
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Islands
U.S. Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip*:
Mailing Address*:
City*:
State*:
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Mariana Islands
Marshall Islands
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Islands
U.S. Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip*:
Phone*:
Fax:
Pharmacy Email*:
Hours of Operation:
M-F*:
Sat*:
Sun*:
Pharmacy Type*:
- Select -
Retail
Retail/LTC Combo
LTC Closed Door
Physician Clinic
Hospital
Indian/Tribal
Government
FQHC
Ownership Structure*:
- Select -
Individual LLC
Partnership LLC
Corporation, Not Public
Corporation, Publicly Traded LLC
Indian/Tribal
Government
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*:
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Mariana Islands
Marshall Islands
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Islands
U.S. Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip*:
Ownership Percent*:
%
Direct Owner?*
Second Owner
Owner Name:
Phone:
Email:
Address:
City:
State:
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Mariana Islands
Marshall Islands
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Islands
U.S. Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Ownership Percent:
%
Direct Owner?
Third Owner
Owner Name:
Phone:
Email:
Address:
City:
State:
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Mariana Islands
Marshall Islands
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Islands
U.S. Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Ownership Percent:
%
Direct Owner?
Fourth Owner
Owner Name:
Phone:
Email:
Address:
City:
State:
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Mariana Islands
Marshall Islands
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Islands
U.S. Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip:
Ownership Percent:
%
Direct Owner?
Fifth Owner
Owner Name:
Phone:
Email:
Address:
City:
State:
- Select -
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Mariana Islands
Marshall Islands
Maryland
Massachusetts
Michigan
Micronesia
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Palau
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
U.S. Minor Islands
U.S. Virgin Islands
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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*:
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