NCPA Innovation Center/CPESN Community Pharmacy Fellowship Enrollment Form
NCPA Innovation Center is excited to start a new class of fellows. This fellowship program allows CPESN members to reach inside the minds and pharmacies of our best practitioners. Prospective pharmacies, please complete the following enrollment form carefully.
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 NCPDP
*
Pharmacy NPI
*
Primary Wholesaler
*
Please Select
AmerisourceBergen
Cardinal Health
McKesson Corp
Mutual Drug Co
Smith Drug Co
Other
Pharmacy Software Provider
*
Please Select
PioneerRx
ComputerRx
Rx30
QS/1
Liberty
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.
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
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
Fellow Email
*
example@example.com
Fellow Mobile Number
*
Please enter a valid phone number.
Select the date range that represents the year the fellow graduated from pharmacy school.
*
2021
2020-2016
2015-2005
Before 2005
Which statement best describes the fellow?
*
Please Select
Existing Employee
Pharmacy Owner
New Employee (hired specifically for the fellowship)
Professional Headshot of the Fellow
*
Browse Files
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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.
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Fellow Self-Assessment
Describe your community pharmacy experience: pre-pharmacy, internships, IPPE, APPE, and professional. This should include roles played (from janitor to technician to change agent).
*
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 Coordinator signs below to indicate they have reviewed the Fellow's Self-Assessment and discussed it with the Fellow.
*
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Pharmacy Coordinator Name
*
First Name
Last Name
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