Sign Me Up 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* ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming 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?* YesNo 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) ---CompoundingCustomized Medication (e.g. flavoring)Vitamin and Nutritional SupplementsDurable Medical EquipmentHome Medical EquipmentMedication Synchronization ServiceMedication Therapy Management ServiceCompliance Packaging ServiceHome Delivery ServicePharmacy ClinicHome Infusion PharmacyImmunization and Travel VaccinationsDisease Management ServicesAsthmaDiabetesHypertensionGeriatric CareWomen’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.) Comments