Independent Pharmacists Contracting Network Llc printable pdf download

Independent Pharmacists Contracting Network Llc

Independent Pharmacists Contracting Network, llc

Date: ________________________

Independent Pharmacists

Please complete the following information in order to give the

Contracting Network, LLC

representation on your behalf for RxPr1de (chain codes 767 &

964), and Managed Pharmacy Care (chain code 600), third party health plan

contracting.

My Pharmacy, _____________________________________________ has contractual

representation by RxPr1de and Managed Pharmacy Care.

Pharmacy NCPDP# ____ - __________________ NPI # ______________________

Pharmacy Name

____________________________________________________

My Name (Print)

____________________________________________________

Address

____________________________________________________

City, State, Zip

____________________________________________________

Phone Number

____________________________________________________

Fax Number

____________________________________________________

Email Address

____________________________________________________

DEA Number

____________________________ Exp. Date ______________

State Pharmacy Lic #___________________________ Exp. Date ______________

Pharmacist License #___________________________ Exp. Date ______________

Medi-Cal (Medicaid) Provider #___________________________________________

Federal Tax ID #

____________________________________________________

Wholesaler

_______________________ Software Vendor:_____________

Hours of Operation ______________________Provide 24 hour Access?  Yes  No

Languages Spoken ____________________________________________________

Liability Insurance Carrier: _______________________________________________

Policy Number: _________________________________ Exp. Date _______________

Signature:____________________________ Title: ____________________________

Independent Pharmacists Contracting Network at P.O. Box 1026 Lake Arrowhead, CA 92352

(We accept VISA/MC payments by phone. Please call 866-336-6692.)

Updated 10-14-10

Independent Pharmacists Contracting Network Llc