Membership Application

GeriMed Rep

Check One: LTC (Closed-Door) PharmaciesCombo PharmaciesRetail 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

Please indicate in the spaces below, the average number of LTC beds/patients serviced monthly:

Skilled Nursing

Assisted Living

Group Home

Intermediate Care (ICF-IID) (formerly ICF-MR)

Mental Health / Psychiatric

Medical at Home

Correctional

Hospice

Home Infusion

*Other

TOTAL

*For Other, please specify type

Notes

Recaptcha - Input code:
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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