Create a Pharmacy Account

* Enter a Username * Enter a Username. This will be used to log in to your account. You cannot change your Username later. This will be used to log in to your account. You cannot change your username later. Username is taken, try another.

* Enter a Password * 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.). Must be 6-15 characters and include at least 2 numbers. Do not use special characters (#,!,$,etc.).

* Confirm Password

* First Name MI Middle initial

* Last Name * Last Name. In order to submit online refill requests, the last name must match exactly with the name on the prescription bottle. 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 AL AK AS AZ AR AE AA AP CA CO CT DE DC FM FL GA GU HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND MP OH OK OR PW PA PR RI SC SD TN TX UT VT VI VA WA WV WI WY

Zip Code

Phone Number

Account is for

Birthdate (mm/dd/yyyy) 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 Prescription Number. This must exactly match the prescription number on the pharmacy record.