NCPA/CPESN Med Sync Fellowship Enrollment Form

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 NameLast Name
Pharmacy Owner Email*
example@example.com
Pharmacy Phone Number*
Please enter a valid phone number.
Pharmacy Website
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pharmacy NPI*
Pharmacy NCPDP*
Primary Wholesaler*
PioneerRxComputerRxLibertyRx30QS/1Other
Select the eCare Plan capable system provided to pharmacy employees.*
Local CPESN Network
Who will be the Pharmacy Coordinator, providing oversight of the fellow and the program at the pharmacy?*

First NameLast 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 NameLast Name
Fellow Title
Fellow Email*
example@example.com
Fellow Mobile Number*
Please enter a valid phone number.
October 2024 - August 2025
20252024-20172016-2006Before 2005
If you are a pharmacist, please enter the year you graduated from pharmacy school.
Which statement best describes the fellow?*
Eastern TimeCentral TimeMountain TimePacific TimeAlaska TimeHawaii Time
Professional Headshot of the Fellow*

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.
Cancelof
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. *

Clear
Pharmacy Owner Name*

First NameLast Name
Date

MonthDayYear
Date
Payment Information

Full tuition due is $3,500 and is nonrefundable.
My Products*
prevnext( 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

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

NCPA/CPESN Med Sync Fellowship Enrollment Form

Pharmacy Information

Fellow Information

Fellow Self-Assessment

Payment Information