-EZSCRIPTRx- - Signup

1. Pharmacy Information

2. Primary Admin User

3. Terms & BAA

4. Review & Payment

NPI(*)

DEA Number(*)

NCPDP(*)

DBA(*)

Legal Name(*)

Address(*)

City(*)

State(*)

Zip(*)

Email(*)

Phone(*)

State(s) Pharmacy Licensed In(*)

Pharmacy Management System(*)

Other Billing Software(*)

First Name(*)

Last Name(*)

Phone(*)

Email(*)

Job Functions(*)

Save & Continue

Plan:

EZSCRIPTRx Advanced Plan (1000 credits for $950 per month)

Coupon:

20% for 3 months on the plan of the bill

Payment:

$760 in the first invoice