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Registration


Please fill out the Registration Application. We use this information to send messages, confirmations, shipping details, provide top-notch customer service and verify all members are licensed pharmacists and/or owners. Once you do so you'll be able to:

  1. Buy prescription drugs at a discount off WAC
  2. Sell overstocked prescription drugs
  3. Use your wish list for prescription drugs you use regularly
  4. Better manage your inventory
  5. Maximize your profits
After completing the application we will verify your status and you will receive an email within one (1) business day validating your application.
Please complete required fields Pharmacy Information
NPI # (0123456789) *
NCPDP # (0123456) *
Legal Business Name *
Doing Business as (DBA) *
Pharmacy Address 1 *
Pharmacy Address 2
Pharmacy City *
Pharmacy State *
Pharmacy Zip Code *
Pharmacy Phone *
Pharmacy Fax *
 
Pharmacy Owner Information
Owner First Name *
Owner Last Name *
Mobile Number *
Email Address *
Email Address (Confirm) *
 
Primary Contact Information
Click here if Primary Contact Information is same as owner
First Name *
Last Name *
Title/Position *
Mobile Number *
Email Address *
Email Address (Confirm) *
Pharmacy License Information
DEA # (AB1234567) *
State License Number *
State License Expiration Date (MM/DD/YYYY) *
Federal Tax Id # *
Pharmacist Questionnaire
Enterprise Type *
Partnership
Corporation
Sole Proprietor
LLC
 
Primary Wholesaler Name*
Secondary Wholesaler Name
Type Of Pharmacy
Promo Code
How did you hear about us?
Referred by
Pharmacies owned?

Terms and Conditions *
I accept the terms and conditions of the MatchRX.com User Agreement.