Membership Application 1Contact2Company Info3Services4Notes GeriMed Rep*(If you have yet to speak with a GeriMed Rep, enter ‘None at the moment’.) Check One* LTC (Closed-Door) Pharmacies Combo Pharmacies Retail Pharmacies Home Infusion Pharmacies Pharmacy Name* Pharmacy Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Contact Name* First Last Title Email* Enter Email Confirm Email Phone*FaxWholesaler (Primary)* Retail Account # (Primary) LTC Account # (Primary) Wholesaler Representative (Primary) Name* Wholesaler Representative (Primary) Phone*Wholesaler (Primary) Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Wholesaler (Secondary) Retail Account # (Secondary) LTC Account # (Secondary) Wholesaler Representative (Secondary) Name Wholesaler Representative (Secondary) PhoneWholesaler (Secondary) Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 Retail Buying Group* DEA # Retail NCPDP # Retail NPI # LTC NCPDP # LTC NPI # Check box if you have not yet been assigned LTC NCPDP and NPI numbers for your combo pharmacy associated with DEA# above. Tax ID State Pharmacy License Other Third Party Affiliation Is this pharmacy under the same ownership of any other pharmacies currently a member of GeriMed?* No Yes (if ‘Yes’, enter required info below) Existing GeriMed /ComboMed/ ‘Network Only’ Affiliation*Pharmacy Group/NameLTC NCPDP Dispensing Software Company*(please list software COMPANY, not software name) Does your pharmacy use a reconciliation vendor?* No Yes Enter Name of Vendor* 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, .pngDEA Certificate CopyAccepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB.Pharmacy PermitAccepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB.State RegistrationAccepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB.Liability Insurance*Accepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB.List of Long Term Care Facilities Serviced(required for some manufacturer contract access)Accepted file types: doc, docx, xls, xlsx, pdf, jpeg, jpg, png, Max. file size: 50 MB. Are you currently dispensing any Long Acting Antipsychotic Injections (LAIs)?*YesNoIf so, how many patients do you service that are receiving LAIs on a monthly basis? Please indicate in the spaces below, the average number of LTC beds/patients serviced monthly:Skilled NursingPlease enter a number greater than or equal to 0.Assisted LivingPlease enter a number greater than or equal to 0.Group HomePlease enter a number greater than or equal to 0.Intermediate Care (ICF-IID) (formerly ICF-MR)Please enter a number greater than or equal to 0.Mental Health / PsychiatricPlease enter a number greater than or equal to 0.Medical at HomePlease enter a number greater than or equal to 0.CorrectionalPlease enter a number greater than or equal to 0.HospicePlease enter a number greater than or equal to 0.Home InfusionPlease enter a number greater than or equal to 0.*OtherPlease enter a number greater than or equal to 0.Total*If 'Other' was indicated above, please explain setting within the Notes box found on next pageHow did you hear about us?*Hidden*For Other, please specify type NotesCAPTCHAPhoneThis field is for validation purposes and should be left unchanged. Prefer to download the application? GeriMed Membership Application for Long Term Care Pharmacies ComboMed Membership Application for Combo Pharmacies RxMed Membership Application for Retail Pharmacies IVMed Membership Application for Home Infusion Pharmacies