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Click ‘Get Form’ to open the Supervising Pharmacist Agreement in the editor.
Begin by entering your last name, first name, and middle initial in the designated fields for the Supervising Pharmacist.
Fill in your Supervising Pharmacist License/Registration number, NPI, and MMIS Provider number accurately.
Next, provide the Pharmacy Name and complete the address section with all required details.
Enter the Pharmacy License/Registration number, NPI, and MMIS Provider number as requested.
Review the agreement statement regarding responsibilities and enter the effective date of your supervision.
Sign and date the form in the appropriate sections to validate your agreement.
The Pharmacy Owner must print their name, sign, and date below their acknowledgment of enrollment requirements.
Finally, ensure a passport-sized photo is affixed to a separate sheet as instructed before submission.

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Versions	Form popularity	Fillable & printable
2016	4.8 Satisfied (247 Votes)
2010	4 Satisfied (47 Votes)

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What is the phone number for eMedNY pharmacy?

If you have any questions or need assistance with your application, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email.

What is a supervising pharmacist?

Supervising pharmacist: A pharmacist with three or more years of post-registration experience who is in whole-time charge (see section 3.4. 1) and is responsible for the day-to- day operation of the pharmacy.