What is the NCPDP Provider ID? 2026

1. Click ‘Get Form’ to open the Provider Network Participation Request Form in the editor.
2. Begin by entering today’s date in the designated field at the top of the form.
3. Select your provider type by checking one of the boxes: Chain, PSAO, or Independent. Fill in your legal name and NCPDP/NPI number.
4. If applicable, provide your affiliate code and name. Choose your pharmacy type from options like Retail, Clinic, or Mail.
5. Complete your pharmacy address details including city, state, zip code, and contact information.
6. In the Additional Information section, answer questions regarding PSAO affiliation and Medicaid dispensing status as required.
7. Finally, fill out the Signature Information section with the name and title of the authorized individual before submitting via fax or email.

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