Prescribers & Pharmacists PMP Registration Info Change Form

DEA Number

Providers: Please type each and every one of your active personal DEA numbers separated by a comma. Pharmacists: Please type your employer DEA number.

DEA Number(s)

First Name

Last Name

NPI

Incorrect Email Address (If you do not know then please leave blank)

Correct Email Address

Last 4 Digits of SSN

License Number (Please make sure to add any leading letters and zeros)

License Type (i.e. MD, DO, RPh, PharmD, DDS, DMD, ARNP, PA, etc.)

Healthcare Specialty

Primary Phone Number

Date of Birth

Please indicate your primary employer address (only one address can be added to your account). If you are retired or unemployed, please indicate your mailing address

Employer

Employer Phone Number

Employer Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country