New Pharmacy Account Setup

Complete this form so we can begin setting up your pharmacy, marketing resources, forms, and portal access. Required fields are marked with an asterisk.

Already a Premier Rx pharmacy? Do not use this form to create a portal password or add a portal user. Set or reset your Pharmacy Portal password here, or contact Premier Rx if another user needs access.

Store Name *

Street Address *

City *

State *

Zip Code *

What is your store's Retail Pharmacy License number? *

Name of the main contact for the Central Fill Program at your store *

Mobile cell # of the main contact for the Central Fill Program at your store *

Pharmacy Phone Number *

Fax Number for Prescriptions *

Will your pharmacy be ordering HRT from Gwinnett Drugs through Central Fill? *

Yes No

Pharmacy DEA Number * Required when your pharmacy will be ordering HRT through Central Fill.

Pharmacy Portal Email Address * This email address will be used to sign in to your Premier Rx Pharmacy Portal account.

If you were referred by another pharmacy, which pharmacy referred you?

If you have not provided your logo yet, please do so here. JPG, PNG, or WebP. Maximum recommended size: 10 MB.

Any Other Comments