Store Profile

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MyHealthMart Information

PSAO Chain Code:

ID/ACCT:

NCPDP:

Sales Manager:

Email:

Phone:

Store Information

Store Name:

Store NPI:

Store Phone Number:

Fax:

Email:

Address:

City:

State:

Zip:

Store Hours

Monday:
Tuesday:
Wednesday:
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Friday:
Saturday:
Sunday:

Monday:
Tuesday:
Wednesday:
Thursday:
Friday:
Saturday:
Sunday:

Monday:
Tuesday:
Wednesday:
Thursday:
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Sunday:

Social Platforms

Website URL: I don't have one

Facebook URL: I don't have one

Instagram: I don't have one

LinkedIn URL: I don't have one

Twitter: I don't have one

YouTube: I don't have one

Pinterest: I don't have one

Contact Information

Contact 1: *

Name:

Role:

Email:

Phone:

Contact 2:

Name:

Role:

Email:

Phone:

Computer Systems & Tools

PSAO Chain Code:

Pharmacy Management System:

Payor Switch Provider:

Point of Sale System:

Yes

Buying Group:

PSAO:

Store Layout

Front End Size (Sq. Ft.):

Private Consultation Space:

Approximate OTC SKUs:

Drive-Thru:

Yes

Store Services Available

Store Services

Medication Therapy Management

Medicare Part B PTAN Number

DME accreditation

Durable Medical Equipment

Wellness Programs

Yes	No	Future	Program Type
			Med Sync/ Appointment based Model Dispensing
			Chronic Conditions Coaching/ Education
			Self Management Skills Training
			Long Acting Injection Administration
			Nutrient Depletion
			Health Screening
			Pharmacogenomics
			Hormone Consulting
			Functional Medicine
			Prescriptive Authority (Chronic Disease Therapy Management)
			Other

Store Profile

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MyHealthMart Information

Store Information

Store Hours

Social Platforms

Contact Information

Contact 1: *

Contact 2:

Computer Systems & Tools

Store Layout

Store Services Available

Store Services

Patient Facing Services

Contracted

Medications

Convenience

Programs

Products & Services

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