Membership Application

GeriMed Rep

Check One: LTC PharmaciesRetail PharmaciesCombo-PharmaciesHome Infusion Pharmacies

Pharmacy Name*

Address*

City*

State* Zip*

Contact Name*

Title

Email*

Phone* Fax


Wholesaler (Primary) City, State

Wholesaler (Secondary) City, State

 

Owner/President

Email

 

Pharmacist in Charge

Email

 

Director of Operations

Email

 

Purchasing Agent

Email

DEA #

Retail NCPDP #

Retail NPI #

LTC NCPDP #

LTC NPI #

Tax ID

State Pharmacy License

Other Third Party Affiliation

Dispensing Software Company

Requested Documents
If you do not currently have these documents, they can be submitted at a later date
Accepted File Types: .doc, .docx, .xls, .xlsx, .pdf, .jpeg, .jpg, .png

DEA Certificate copy

Pharmacy Permit

State Registration

List of Long Term Care Facilities Services

Number of Beds On Site Off Site

Number of IV Infusion/Homecare Beds

Number of ICF-MR Beds

Number of Group Home Beds

Number of IMD (Institutions for Mental Diseases) Beds

Number of Independent Living Beds

Number of CMHC (Community Mental Health Center) Beds

If Offsite, number of nursing homes served

Number of Skilled and intermediate care beds serviced

Home Care Services, average number of patients serviced per month

Jails and prisons, average number of patients serviced per month

Hospice

Assisted Living, number of beds serviced

Psychiatric group homes/chronic psychiatric facilities

Number of other types of patients served

Other beds or patients serviced (explain)

Notes

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Prefer to download the application?

GeriMed Membership Application for Long Term Care Pharmacies

RxMed Membership Application for Retail Pharmacies

IVMed Membership Application for Home Infusion Pharmacies