Pharmacy Portal Self Signup

Help us understand why you are requesting access to the Pharmacy Portal.

Please select the option below which best describes your need
	I represent a pharmacy that is currently contracted as a Caremark Provider and need access to the various tools on the Pharmacy Portal.
	I represent a pharmacy that would like to enroll to become a Caremark Provider OR this is a pharmacy change of ownership request.

Enter the Pharmacy Details for the Provider already contracted with Caremark

Enter the Pharmacy Details for the Provider who needs the Enrollment Application

Pharmacy Name*

Pharmacy Address*

Pharmacy Address 2 (Optional)

City*

State*

5 Digit Zip Code*

Phone Number*

Fax Number*

NCPDP*

Pharmacy NPI*

FEIN*

State License*

DEA*

Help us understand who you are

Desired User Name*

Job Title*

First Name*

Last Name*

Email Address*

Re-enter Email Address*

Are you an Authorized Representative who can sign contracts on behalf of the pharmacy? Yes
No

I have read and agree to these terms of use of the Pharmacy Portal

UNAUTHORIZED ACCESS AND USE: A user account may only be utilized by the pharmacy CVS Caremark approves as part of the user account registration process. By logging onto the Pharmacy Portal, you represent that you have the requisite authority to access the user account for which you have been authorized by CVS Caremark. Users must not access an account belonging to another user.