Request Application to Join the Pharmacy Network

Please complete the form below to get an application to join Aetna’s network:

All fields marked with a RED asterisk (*) are required in order to proceed.

Pharmacy contact name

*Pharmacy name

Change of ownership

Yes

*NCPDP number

National Provider Identifier (NPI)

*Pharmacy Address

P.O. Box

*Phone Number

Pharmacy specialty

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Do you have Aetna insurance through an employer or are you a Medicare member? Yes No

Do you have Aetna insurance through an employer or are you a Medicare member? Yes No