Pharmacy Portal Self Signup

Enter your pharmacy information below to register for online access

Select an option below to help us understand why you are requesting access to the Pharmacy Portal.*
	I represent a pharmacy that is already a Caremark Provider and I need online access.
	I represent a pharmacy that would like to enroll to become a Caremark Provider OR this is a pharmacy change of ownership request.

Job Title*
First Name*
Last Name*
Does this person represent the pharmacy as an authorized representative? (e.g. can sign contracts on behalf of the pharmacy)*
	Yes No
Email Address*
Re-enter Email Address*
User Name*
Pharmacy Name*
Pharmacy Address1*
Pharmacy Address2
City*
State*
Zip*
Phone Number*
Fax Number*
Pharmacy NPI*
NCPDP*
FEIN*
State License*
DEA*