Join Form - My ASP.NET Application
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 800.755.1229 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*: