NCPDP

NPI (if new NCPDP issued)

Doing Business As (DBA) Name

Legal Name

Tax ID (EIN)

Address (include county)

City

State

ZIP Code

County

Phone

Fax

Effective Date of Transaction (MM/DD/YYYY)

Type of Ownership Change Type of Ownership Change *Stock purchaseAsset purchasePartner transferFamily buyout

Proof of Ownership Available Proof of Ownership Available Power of Attorney (POA) Bill of Sale (BOS) Not Available

Upload Proof of Ownership Upload Proof of OwnershipFile InputChoose FilesNo Files ChosenAccepted file types: pdf, docx. Max. file size: 1 MB

If proof of ownership is not available, what is the expected date to obtain this document? (MM/DD/YYYY)

New Owner Full Name

Phone

Email

New Owner Percentage

Partner Name If this is a partnership, please provide details for each partner.

Phone

Email

Partner Percentage

Partner Name

Phone

Email

Partner Percentage

Have the following been notified of the ownership change? (Check all that apply.) Have the following been notified of the ownership change? (Check all that apply.) NCPDP NPI State Board of Pharmacy DEA

Current Data Vendor

Current Switch Vendor