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. 
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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

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Please select your time zone: