Medical Matrix

Contract Request
Thank you for your interest in Matrix's Contract Service. Please complete the form below to request a contract packet. Fields in Red are required. Either the NCPDP number or Chain Code is required. If you provide us with the Chain Code number, indicate number of stores.

Pharmacy Information:
Pharmacy Name*
NCPDP Number
Chain Code
Number of stores
Federal Tax ID EIN Number*
NPI Number
DEA Number
What type of Pharmacy?	Retail Pharmacy Long Term Care Closed Door Other
If other, please specify:
Is the Pharmacy open 24/7?	Yes No
Is the Pharmacy handicap accessible?	Yes No
Does the Pharmacy have a mail order facility?	Yes No
Contact Person:
First Name:*
Last Name:*
Phone:*
Fax:
Email Address
Mailing Address:
Street:*
City:*
State:*
Zip:*
Physical Address: Physical Address same as Mailing Address
Street:
City:
State:
Zip
Pharmacy Currently processing Medicare Yes No
Current Processor
National Supplier Clearinghouse Number (NSC)
Effective Date
Pharmacy Currently processing Tricare Yes No
Current Processor
Effective Date