PROVIDER REGISTRATION
Thank you for registering for MyBrand-Rx services! Your responses to the important questions below are the first step to enabling our staff to better serve you and your valued patients. We do not share the information below with any third party companies. A MyBrand-Rx representative will contact you shortly.
Copyright 2013 MyBrandRx, LLC
First Name *
Middle Initial
Last Name *
Title *
Practice Name *
Address 1 *
Address 2
City *
State *
Zip Code *
Office Phone Number *
Mobile Phone Number
Fax Number *
Email Address *
Provider NPI*
Practice Web Address
Please include the following important information:
Staff member to contact if missing patient information? *
Staff member that handles insurer and PBM prior authorizations? *
How did you hear about MyBrand-Rx?
Do you e-prescribe? *
If so, which e-Rx vendor?
OFFICE HOURS * (Required)
Start Time Stop Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Please select your time zone:
