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*:

- Select - ALABAMA ALASKA American Samoa ARIZONA ARKANSAS CALIFORNIA COLORADO CONNECTICUT DELAWARE District of Columbia Federated States of Micronesia FLORIDA GEORGIA Guam HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE Marshall Islands MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA Northern Mariana Islands OHIO OKLAHOMA OREGON Palau PENNSYLVANIA Puerto Rico RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT Virgin Islands 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 Federated States of Micronesia FLORIDA GEORGIA Guam HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE Marshall Islands MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA Northern Mariana Islands OHIO OKLAHOMA OREGON Palau PENNSYLVANIA Puerto Rico RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT Virgin Islands 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 Federated States of Micronesia FLORIDA GEORGIA Guam HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE Marshall Islands MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA Northern Mariana Islands OHIO OKLAHOMA OREGON Palau PENNSYLVANIA Puerto Rico RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT Virgin Islands 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 Federated States of Micronesia FLORIDA GEORGIA Guam HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE Marshall Islands MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA Northern Mariana Islands OHIO OKLAHOMA OREGON Palau PENNSYLVANIA Puerto Rico RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT Virgin Islands 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 Federated States of Micronesia FLORIDA GEORGIA Guam HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE Marshall Islands MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA Northern Mariana Islands OHIO OKLAHOMA OREGON Palau PENNSYLVANIA Puerto Rico RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT Virgin Islands 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 Federated States of Micronesia FLORIDA GEORGIA Guam HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE Marshall Islands MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA Northern Mariana Islands OHIO OKLAHOMA OREGON Palau PENNSYLVANIA Puerto Rico RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT Virgin Islands 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 Federated States of Micronesia FLORIDA GEORGIA Guam HAWAII IDAHO ILLINOIS INDIANA IOWA KANSAS KENTUCKY LOUISIANA MAINE Marshall Islands MARYLAND MASSACHUSETTS MICHIGAN MINNESOTA MISSISSIPPI MISSOURI MONTANA NEBRASKA NEVADA NEW HAMPSHIRE NEW JERSEY NEW MEXICO NEW YORK NORTH CAROLINA NORTH DAKOTA Northern Mariana Islands OHIO OKLAHOMA OREGON Palau PENNSYLVANIA Puerto Rico RHODE ISLAND SOUTH CAROLINA SOUTH DAKOTA TENNESSEE TEXAS UTAH VERMONT Virgin Islands 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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