Membership Application- Long Term Pharmacy

GeriMed Rep*

(If you have yet to speak with a GeriMed Rep, enter ‘None at the moment’.)

Check One*

Pharmacy Name*

Pharmacy Address*

Street Address Address Line 2 City State ZIP Code

Contact Name*

First Last

Title

Email*

Enter Email Confirm Email

Phone*

Fax

Wholesaler (Primary)*

Retail Account # (Primary)

LTC Account # (Primary)

Wholesaler Representative (Primary) Name*

Wholesaler Representative (Primary) Phone*

Wholesaler (Primary) Address

City State

Wholesaler (Secondary)

Retail Account # (Secondary)

LTC Account # (Secondary)

Wholesaler Representative (Secondary) Name

Wholesaler Representative (Secondary) Phone

Wholesaler (Secondary) Address

City State

Owner/President

First Last

Email

Pharmacist in Charge

First Last

PIC License*

Accepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB.

Email

Director of Operations

First Last

Email

Purchasing Agent

First Last

Email

Pharmacy Group/Name	LTC NCPDP