How To Join

Shortcuts

Medical

Dental

Behavioral Health

Clinical Policy Bulletins

Formulary

Aetna Specialty Pharmacy

Help/FAQs

How To Join

Please select your segment

Pharmacy - Online Request For Network Participation

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

Please provide the following information:
Pharmacy Contact Name:
*Pharmacy Name:
Change of Ownership:		Yes No
*NCPDP Number:
National Provider Identifier (NPI):
*Pharmacy Street Address:
P.O. Box:

*City:
*State:
*Zip Code:
*Phone Number:
*Pharmacy Specialty:
DME providers please contact the Credentialing Customer Service Unit at 1-800-353-1232 for contracting information.

Pharmacy Professionals

Information Sessions

Your request has been sent successfully if you receive a confirmation after clicking the "Submit" button.

Important! Please check this form carefully before clicking on the "Submit" button. Some browsers will not keep your information, and you will have to re-type all of it if you miss filling in any of the required fields.