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Pharmacy Information

NCPDP*:

NPI*:

Tax ID*:

Pharmacy DBA Name*:

Pharmacy Legal Name*:

Physical Address*:

City*:

State*:

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Zip*:

Mailing Address*:

City*:

State*:

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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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