Independent Pharmacists Contracting Network Llc (Page 2 of 2) in pdf

Pharmacy Name ______________________ NCPDP#____ - ____________

Corporation Name______________________ DBA______________________________

Medicare Part B Provider?  Yes  No

Administer Vaccines?  Yes  No

Part B Processor_____________________ NSC #____________________________

LTC and Retail Pharmacy  Yes  No

LTC Pharmacy Only?  Yes  No

MTM Participant?  Yes  No If yes, which plans: ________________________

_____________________________________________________________________

Billing Pharmacist Name_______________________ NPI #_____________________

For prompt enrollment to the third-party health plan contracts available, please

review, complete and return all documents requested, ensuring your pharmacy

name and NCPDP number are on all paperwork, so that your store will be easily

identified.

Contract/Affiliation Letter. This letter is required by the NCPDP to show your pharmacy is



affiliated with RxPr1de, and must be signed by the owner or Pharmacist in Charge.

Business Associate/Trade Partner Agreement. HIPAA requirement for communications with



PBM’s about patient information.

PLEASE PROVIDE COPIES OF THE FOLLOWING:

 Copy of NPI Confirmation Letter (NPI#___________________________________)

 Employer Federal Tax Identification Certificate

Letter from IRS with the pharmacy business

legal name and tax ID. If you do not have this available you can request a copy of the letter to be

faxed to you by calling 800-829-4933.

(Also accepted is Federal Tax Deposit Coupon, form 8109 or Payment

Voucher, form 941-V.)

 Copy of current Federal DEA License (________________)

 Copy of current State Pharmacy License (PHY____________)

 Copy of Pharmacist License (RPH____________)

 Copy of Medicare/Medi-Cal License Number (________________)

 Copy of DME Certificate of Accreditation or Exemption Letter (If Applicable)

 Copy of Business License

 Copy of General Insurance License with your policy number, limits, and expiration.

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 Page 2