Fill out the enrollment form below, then click the [Submit] button.
Pharmacy First will automatically generate the required documents for your pharmacy and mail them to you.
Place your signature where required and fax those pages back to Pharmacy First.
I understand that by submitting the below form, that I am requesting enrollment in the Rx$hare Rebate Program.
I also understand that my scrubbed dispensing data (non-PHI) will be aggregated with the other 3,500 pharmacies in the network, and that I will be provided rebates based on my active participation with the designated preferred products and other program initiatives.
I also understand that, while there is no upfront sign-up or membership fees, administrative costs and costs to secure my necessary data will be subtracted from my qualifying rebate.
Note: If you are enrolling multiple Pharmacies, you must submit a separate form for each Pharmacy.
(Press the Tab and Shift-Tab key to navigate from field to field)
Pharmacy Name
*
Pharmacy Legal Name
*
NCPDP/NABP
*
Phone Number
*
Fax Number
*
Email Address
*
Software Vendor
*
Switch Company
*
Owner's Name
*
Primary Contact
Compliance Contact
Primary Wholesaler
*
Secondary Wholesaler
GPO
Authorized Signature Name
*
(As signed)
Title
Required fields are marked with * (asterisk)
*
Please check your input carefully before you click the [Submit] button.
(To start over and clear all fields & erros, click here)
All information will remain confidential and will not be shared with any third party.