This electronic form is intended to declare that a current CPESN USA participating pharmacy location operates with one or more organizational NPI and are physically based at the single location.
Please note: CPESN USA Participation Fee rates are allocated based on CPESN USA Board of Managers approved policy changes are effective July 1, 2025. Effective July 1, 2025: pharmacy shall pay to CPESN a participation fee of one hundred- and twenty-five-dollars ($125.00) per month (the “Participation Fee”) per store location.
Instructions for this form.
Note: Record updates may be delayed if NPIs submitted in this form do not match the official CPESN USA participation records. If an NPI is not yet a participating pharmacy with CPESN USA, please go to https://join.cpesn.com and complete the onboarding process. Upon completing all onboarding steps, please return to this form to declare multiple NPIs working under the one location.
1. Enter the NPIs below that meet the single location criteria - these NPIs should be existing CPESN USA pharmacies and should be pharmacy NPIs, not individual pharmacist NPIs. A minimum of two (2) NPIs are required for this declaration (e.g. Retail/Community Pharmacy NPI & Long-Term Care NPI). However, additional NPIs can be added under which are in physically based in the same location and meet the requirements to participate under the Clinically Integrated Network.
2. Complete the contact section of this form – enter the current pharmacy business lead which CPESN USA may contact as needed as it relates to this form declaration of the entered NPIs.
3. Complete the address section of this form – enter the physical location address which business mailings may be received.
4. Submit form.