New Pharmacy Enrollment Form
Provider Information
NCPDP #
NPI #
Phone:
Fax:
Pharmacy Legal Name:
DBA Name (if any):
Street Address:
City:
County:
State:
Zip:
Required Signature The undersigned is authorized to execute the contract on behalf of the pharmacy and accepts the network rates and ancillary charges to participate in the Spectrum Pharmacy Solution LLC network.
Owner or Primary Contact Legal Name:
Title:
Email:
Signature:
Date:
I agree to the terms and conditions
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