Rx$hare Enrollment Form

TOLL FREE: 888-800-DRUG

Rx$hare Enrollment Form

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)

Rx$hare Enrollment Form
Pharmacy Name*	(Full Legal Name)
NCPDP/NABP*	Pharmacy NPI <-your Pharmacy NPI number
Phone Number*	(Example: 913-123-4567)
FAX Number*	(Example: 913-123-4567)
Pharmacy Address*	Street City State Zip Code
Mailing Address If different from Pharmacy Address	Street City State Zip Code
Email Address*	Example: myname@mydomain.com
Software Vendor*
Switch Company*
Owner´s Name*
Primary Contact	(If different than Owner)
Primary Wholesaler
Secondary Wholesaler
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 & errors, click here) All information will remain confidential and will not be shared with any third party.