[4.5 Live] Contact-Free Vaccination Pharmacy Enrollment

My Information

Please complete the required fields below.

First Name *

Last Name *

Title/Role at Pharmacy

My Email Address *

Enrollment confirmation email is sent here

Monthly Subscription Options

Enter the total number of pharmacies you would like to enroll below to proceed.

1 to 50 Pharmacies $30 a month, per pharmacy

Only $7.50 a week.
Billed every month.
12-month agreement.

51 to 100 Pharmacies $25 a month, per pharmacy

Only $6.25 a week.
Billed every month.
12-month agreement.

101+ Pharmacies $20 a month, per pharmacy

Only $5.00 a week.
Billed every month.
12-month agreement.

Total Pharmacies Enrolling *

Total Monthly Cost:{totalMonthlyCost}

Total Monthly Cost

Today's Date

productcoordinators@prescribewellness.com

Pharmacy Entry

Pharmacy Enrollment Information

Please complete all required fields below for this pharmacy.

Pharmacy One

Pharmacy Name *

First Name *

Primary Contact at Pharmacy

Last Name *

Primary Contact at Pharmacy

Pharmacy NCPDP *

Must be 7 digits

Pharmacy NPI *

Must be 10 digits

Pharmacy Email Address *

When a patient signs up for a vaccination at this pharmacy, a notification will be sent to this email address. This email should be accessible to the pharmacy staff.

Phone Number *

Please enter a valid phone number.

Fax *

Please enter a valid phone number.

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Pharmacy Two

Pharmacy Name *

First Name *

Primary Contact at Pharmacy

Last Name *

Primary Contact at Pharmacy

Pharmacy NCPDP *

Must be 7 digits

Pharmacy NPI *

Must be 10 digits

Pharmacy Email Address *

When a patient signs up for a vaccination at this pharmacy, a notification will be sent to this email address. This email should be accessible to the pharmacy staff.

Phone Number *

Please enter a valid phone number.

Fax *

Please enter a valid phone number.

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Pharmacy Three

Pharmacy Name *

First Name *

Primary Contact at Pharmacy

Last Name *

Primary Contact at Pharmacy

Pharmacy NCPDP *

Must be 7 digits

Pharmacy NPI *

Must be 10 digits

Pharmacy Email Address *

When a patient signs up for a vaccination at this pharmacy, a notification will be sent to this email address. This email should be accessible to the pharmacy staff.

Phone Number *

Please enter a valid phone number.

Fax *

Please enter a valid phone number.

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Pharmacy Four

Pharmacy Name *

First Name *

Primary Contact at Pharmacy

Last Name *

Primary Contact at Pharmacy

Pharmacy NCPDP *

Must be 7 digits

Pharmacy NPI *

Must be 10 digits

Pharmacy Email Address *

When a patient signs up for a vaccination at this pharmacy, a notification will be sent to this email address. This email should be accessible to the pharmacy staff.

Phone Number *

Please enter a valid phone number.

Fax *

Please enter a valid phone number.

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Pharmacy Five

Pharmacy Name *

First Name *

Primary Contact at Pharmacy

Last Name *

Primary Contact at Pharmacy

Pharmacy NCPDP *

Must be 7 digits

Pharmacy NPI *

Must be 10 digits

Pharmacy Email Address *

When a patient signs up for a vaccination at this pharmacy, a notification will be sent to this email address. This email should be accessible to the pharmacy staff.

Phone Number *

Please enter a valid phone number.

Fax *

Please enter a valid phone number.

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Pharmacy Entry

Pharmacy Enrollment Information

You have chosen to enroll {totalPharmacies} pharmacies. To make things easy for large pharmacies, we are offering the option to use our Pharmacy Enrollment template.

Follow These Simple Steps

Download the Pharmacy Enrollment Template.
Enter the required information and save the completed file.
Upload the completed Pharmacy Enrollment file below.

Download Pharmacy Enrollment Template

Upload Completed Pharmacy Enrollment File *

Must be a valid spreadsheet or CSV file (.xls, .xlsx, .csv, .numbers).

Pharmacy Payment Information

By entering your payment information below, you are authorizing PrescribeWellness to bill your pharmacy monthly, however the billing cycle will not begin until your enrollment has been confirmed and activated.

Payment Information

USD Monthly Subscription Total

Credit Card
First Name on Credit Card	Last Name on Credit Card
Credit Card Number	Security Code
Card Expiration

From PrescribeWellness