What is the NCPDP Provider ID? 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering today’s date in the designated field. This helps track when the form was completed.
3. Fill in your provider legal name, followed by your NCPDP/NPI number. If applicable, include your affiliate code and select whether you are part of a chain, PSAO, or independent provider.
4. Indicate your pharmacy type by checking the appropriate box (e.g., Retail, Clinic, Outpatient Hospital).
5. Provide your pharmacy address details including city, state, zip code, and contact information such as name, email, phone number, and fax.
6. In the additional information section, answer questions regarding PSAO affiliation and ownership changes. Be sure to provide any necessary dates and Medicaid IDs if applicable.
7. Finally, complete the signature information with the name and title of the authorized individual before submitting via fax or email as indicated at the bottom of the form.

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