CPESN NY Local Fee Collection Tool

CPESN NY Local Fee Collection Tool

This form is being utilized by CPESN NY to collect the local monthly fee associated with being a member of the network.
Pharmacy Point of Contact Name*

First NameLast Name
Pharmacy Point of Contact Email*
[email protected]
Pharmacy Point of Contact Phone Number*
Please enter a valid phone number.
Please Enter Pharmacy Legal Entity Information*
Please enter the Legal Organization or Company Name under which the Pharmacy is organized.
Pharmacy DBA Information
If organization operates under a DBA, please include this information.
Pharmacy NPI Information*
Please enter the Organization's NPI information
Physical Pharmacy Address*

Street Address

Street Address Line 2

CityState

Zip Code
Use same address for Credit Card Billing Address

YesNo
Credit Card Billing Address*

Street Address

Street Address Line 2

CityState

Zip Code

CPESN NY Dues Selection*

CPESN NY Monthly DuesYou will not be charged today, but charges will start on the 5th of the next month and each month afterwards.

Free for the first day then, $25.00 for each month

CPESN NY Yearly DuesYou will not be charged today, but charges will start on the 5th of the next month and then annually after that date.

Free for the first day then, $300.00 for each year

Total

$0.00

By clicking on Submit, I authorize CPESN NY, LLC to charge my credit card above for agreed upon amount. I understand that my information will be saved on file for future transactions on my account. This authorization may be modified or cancelled at any time by contacting us at [email protected]. This authorization will remain in effect until cancelled.
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