NCPA/CPESN Med Sync Fellowship Enrollment Form
The NCPA Innovation Center and CPESN are pleased to welcome a new cohort of fellows to our redesigned Medication Synchronization Fellowship Program. This nine-month, implementation-focused experience provides pharmacies with guided coaching, proven systems, and best-practice strategies from high-performing Med Sync practitioners nationwide. If you're ready to build a scalable, efficient, and profitable Med Sync service, please complete the enrollment form below.
Pharmacy Information
Pharmacy Name
*
Pharmacy NCPA Member ID Number
*
Pharmacy Owner Name
*
First Name
Last Name
Pharmacy Phone Number
*
Please enter a valid phone number.
Pharmacy Website
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Pharmacy NPI
*
Pharmacy NCPDP
*
Primary Wholesaler
*
Please Select
AmerisourceBergen
Cardinal Health
McKesson Corp
Mutual Drug Co
Smith Drug Co
Value Drug Co
Other
Pharmacy Software Provider
*
PioneerRx
ComputerRx
Liberty
Rx30
QS/1
Other
Select the eCare Plan capable system provided to pharmacy employees.
*
Please Select
Amplicare
Assurecare
Azova
BestRx
ComputerRx
Datascan
DocsInk
DocStation
FDS
habitnu
Liberty
McKesson
OmniSYS
Parmetika
PioneerRx
PrescribeWellness
PrimeRx
QS/1
Rx30
Local CPESN Network
Who will be the Pharmacy Coordinator, providing oversight of the fellow and the program at the pharmacy?
*
First Name
Last Name
Pharmacy Coordinator Email
*
example@example.com
Pharmacy Coordinator Mobile Phone Number
*
Please enter a valid phone number.
Why do you want your pharmacy to participate in the fellowship program?
*
Fellow Information
Fellow Name
*
First Name
Last Name
Fellow Title
Please Select
PharmD
RPh
Technician
Community Health Worker
Pharmacist Intern
Fellow Email
*
example@example.com
Fellow Mobile Number
*
Please enter a valid phone number.
Which term would they like to join?
*
October 2024 - August 2025
If a pharmacist, please select the date range that represents the year the fellow graduated from pharmacy school.
2025
2024-2017
2016-2006
Before 2005
If you are a pharmacist, please enter the year you graduated from pharmacy school.
Which statement best describes the fellow?
*
Please Select
Existing Employee
Pharmacy Owner
New Employee (hired specifically for the fellowship)
Which time zone will the fellow be practicing in?
*
Eastern Time
Central Time
Mountain Time
Pacific Time
Alaska Time
Hawaii Time
Professional Headshot of the Fellow
*
Browse Files
Drag and drop files here
Choose a file
This should be a high resolution jpeg file of just the fellow in professional dress. It should not be a cropped photo from a group shot.
Cancel
of
Fellow Self-Assessment
Describe your community pharmacy experience: pre-pharmacy, internships, IPPE, APPE, and professional. This should include all roles and responsibilities throughout your career.
*
Describe any involvement with CPESN and/or Flip the Pharmacy up to this point in your career.
*
Describe your experience working with and leading teams.
*
Why do you want to participate in the fellowship and what do you hope to accomplish?
*
Pharmacy Owner signs below to indicate they have reviewed the Fellow's Self-Assessment and discussed it with the Fellow.
*
Pharmacy Owner Name
*
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Payment Information
Full tuition due is $3,500 and is nonrefundable.
My Products
*
prev
next
( X )
Tuition
Your one-time $3,500 payment serves as the full tuition for the fellowship program and includes all program activities for its duration.
$
3,500.00
Payment Methods
Debit or Credit Card
Choose from one of the PayPal options to
make your payment.
Submit Application
Should be Empty: