Add New Prescription

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Add new prescription	Required info shown in red.

Who the prescription is for:
Drug Name:	, Preference: Brand-name, Generic
Drug Strength:
Doctor's Name:
D.E.A Number:
NPI Number:
Doctor/Clinic Phone Number:
Doctor/Clinic Street:
Doctor/Clinic City:
Doctor/Clinic State
Doctor/Clinic Zip:
Insurance Card Information
Provider’s Name:
Provider’s Phone Number:
RX Bin Number:
(PCN) Processor Control Number:
ID Number:
RX Group Number:
Upload Your Prescription:	(Maximum size:3MB)
OR Fax/Mail your prescription details:	(Check this box if you are faxing in your prescription - no upload is neccessary ) (Check this box if you are mailing in your prescription - no upload is neccessary )

Please fax your prescription and insurance information to:1-866-837-2104**
** Once we receive your information, we will attach it to your prescription and then process your order. If additional information is needed, you will be notified

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