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Pharmacy
Prescriber
Patient
Payor
Pharma
Home
Solutions
Accreditation
Prescriber Engagement
Specialty Support Hub
Turn-Key Specialty Program
Technology
KETU
®
Platform
ProntoRx
®
Specialties
About Us
Company
Careers
News
Contact Us
Login
KETU
®
ProntoRx
®
Solutions Self-Service
Pharmacy
Prescriber
Patient
Payor
Pharma
Pharmacy Background Information
First Name
*
Last Name
*
Title
*
Email
*
Pharmacy Legal Business Name
*
Pharmacy DBA Name
*
Owner's Name (If you are not the primary owner)
No. of Pharmacies
*
Address Line 1
*
Address Line 2
City
*
State
*
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Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Zip
*
Phone
*
Fax
Year Established
*
Pharmacy Location Type (e.g. Closed-Door, Warehouse, Chain, Strip Mall, etc.)
*
Do you have a Sales Person on Staff?
*
Yes
No
What do they sell or market?
Average Annual Revenue (Total for All Locations)
*
Average Annual Number of Prescriptions Filled (For All Locations, All Prescriptions, not just Specialty)
*
Average Annual Number of Prescriptions Filled (For All Locations, All Prescriptions, not just Specialty)
*
What is your Pharmacy Management System?
*
Do you provide other Services at your Pharmacy? (To Select Multiple Services that Apply, Hold Ctrl and Select All that Apply)
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Compounding
Customized Medication (e.g. flavoring)
Vitamin and Nutritional Supplements
Durable Medical Equipment
Home Medical Equipment
Medication Synchronization Service
Medication Therapy Management Service
Compliance Packaging Service
Home Delivery Service
Pharmacy Clinic
Home Infusion Pharmacy
Immunization and Travel Vaccinations
Disease Management Services
Asthma
Diabetes
Hypertension
Geriatric Care
Women’s Health
Describe your current Specialty Business (include therapies you currently dispense)
*
How many specialty pharmacy prescriptions do you fill on average each month in total for all locations you own / operate? (Specialty medications include medications to treat immunologic disorders, Multiple Sclerosis, Oncology, Hepatitis C, HIV, Osteoporosis (injectables only), Behavioral health (injectables only), etc.)
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