Pharmacy Benefit Manager License System

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Initial Application



Enter all required information and click Submit. 

* Required  

* Exact legal name of the Pharmacy Benefit Manager (PBM):

* FEIN/SSN:
 
 * Is the PBM doing business under a name different than the legal name?

If yes, provide name:

* Contact Last Name:

* Contact First Name:

Contact MI:

* Title:

* Email:
 
* Confirm Email:
 
* Business Phone:

Alternate Phone:

* Business Address 1:

Business Address 2:

* City:

* State:

* Zip:

* Country: