Get Medtrakrx Independent Pharmacy Credentialing Application

The MedTrakRx Independent Pharmacy Credentialing Application is a crucial document for pharmacies seeking to participate in the MedTrakRx Pharmacy Network. This guide provides clear and comprehensive instructions on how to accurately complete the application online.

Follow the steps to effectively complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by populating the General Provider Information section. Ensure you enter your NCPDP number, Chain Code, NPI number, Store number, Provider Legal Name, Provider DBA Name, and complete the Physical Address fields including Building/Suite number, City, County, State, and Zip code.
3. Next, indicate whether there has been any change of ownership in the last 18 months by checking 'Yes' or 'No.' If applicable, provide the Date Opened/Acquired.
4. Fill out the Contact Information section with your Mailing Address, Owner’s Legal Name, primary contact details, and after-hours phone number. Additionally, consent to contact through the provided fax number and email address.
5. Complete the Pharmacy Operations section, addressing questions on after-hours services, delivery services, and hours of operation. Specify if your pharmacy operates 24 hours.
6. Select the appropriate options in both the Location description and Provider Class sections, as well as the Provider Type section.
7. Check all applicable services provided by your pharmacy and indicate the languages spoken by your staff.
8. Provide detailed Ownership Information by listing any individuals with ownership or controlling interest, including their names, home addresses, dates of birth, and ownership percentages.
9. Outline Pharmacy Staff details, listing the Pharmacy Manager and Pharmacist(s) along with their licenses and dates of birth.
10. Address the Member Access questions thoroughly, providing explanations where necessary based on your pharmacy's operations and history.
11. If applicable, complete the Mail Order section detailing your pharmacy's capabilities and state licenses for mail-order services.
12. Review the Operational Assessment and Compounding sections, ensuring all questions are answered correctly.
13. Finally, complete the Certification and Signature section with your signature, printed name, title, and date. Ensure all information provided is accurate before submission.
14. Once completed, download, print, or save your application for your records.

Complete your application online to ensure a smooth credentialing process.