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MC-Rx Better Health

Pharmacy Registration Form

Chain or Independent(*)

CHAININDEPENDENT Invalid Input

Chain Name (if applicable)(*)

Please type the name of your Chain

Chain / Affiliation Code(*)

Please provide the affiliation code!

Pharmacy Name(*)

Please type the name of your Pharmacy.

Pharmacy NPI(*)

Invalid Input

Pharmacy NCPDP(*)

Invalid Input

Street Address(*)

Please provide a valid address

State(*)

Please select your state.

Zip Code(*)

Please provide a valid zipcode

First and Last Name(*)

Please provide your First and Last Name

Position Title(*)

Please provide your position within the pharmacy

Telephone Number(*)

Please provide a valid phone number

E-mail(*)

Please provide a valid e-mail!

Password(*)

Please enter a password!

Verify Password(*)

Retype the password!