CPESN Universal Disenrollment Form

CPESN Universal Disenrollment Form

This form is used to notify CPESN USA of your intent to disenroll as a participating pharmacy at the NPI level from CPESN USA, LLC. To disenroll more than one NPI, please complete this form as needed.
Name of Primary Contact*

First NameLast Name
Primary Contact Email*
[email protected]
Primary Contact Phone Number*
Legal Name of Participating Pharmacy
Pharmacy DBA*
Please provide if applicable
NCPDP #*
NPI #*
Please Select Your Current Local CPESN Network:*
Reason for Disenrollment*
Details for Reason for Disenrollment. Feedback is greatly appreciated but not required.
Should be Empty: