Create a Pharmacy Account

* Indicates a required field.

Basic Account

Complete the following information for access to basic online pharmacy services.

Create Username and Password

* Enter a Username. This will be used to log in to your account. You cannot change your Username later.

* Enter a Password. Must be 6 to 15 characters and include at least two numbers. Do not use special characters (number sign, exclamation mark, dollar sign, etc.).

* Confirm Password

Your Information

* First Name Middle initial

* Last Name. In order to submit online refill requests, the last name must match exactly with the name on the prescription bottle.

* Email Address

* Confirm Email Address

Address 1

Address 2

City

State

Zip Code

Phone Number

Prescription Information - Optional

For access to your prescription profile and point-and-click "Whenever Wherever" refill service, provide your Birthdate, specify a recent prescription number, and select the pharmacy where the prescription was filled. For security purposes, this information must exactly match the information in the pharmacy records.

Account Information

Account is for

myself

my child or legal dependent

Birthdate in month month slash day day slash year year year year format. This must exactly match the Birthdate on the pharmacy record.

Prescription Number. This must exactly match the prescription number on the pharmacy record.

Upon successful registration for your online prescription profile, you will be issued a confidential PIN that is required to activate your online Rx Profile. Your PIN will be emailed to the address you specified above in your account registration. To ensure that your mail server will accept this email, please add the following email address to your Approved Senders list: webmaster@nhin.com