Home
Medicare / Medicaid Programs
Sign In
Contact Us
text size
a
a
a
United States
hamburger overlay
menu
search
close
Roche
Home
Medicare / Medicaid Programs
Sign In
Contact Us
1
Create your user account
2
Provide pharmacy information
3
Provide headquarter information
4
Provide store information
Your Information
* Denotes a required field
Full Name
*
First Last
Job Title
i.e. Head Pharmacist
E-mail
*
i.e. user@domain.com
Password
*
This will be your password when you sign in.
The password does not include enough variation to be secure.
Password must contain at least one uppercase character.
Password must be at least 8 characters in length.
Password must contain at least one lowercase character.
Password must contain at least one alphanumeric (letter or number) character.
Password must contain at least one punctuation (not whitespace or an alphanumeric) character.
Confirm Password
*
Please re-type your password to ensure it is correct.
Authorized Representative
*
Authorized Representative
*
I am an authorized representative of this pharmacy
I am NOT an authorized representative of this pharmacy
Federal Tax Id
*
i.e. 123456789
DEA Registration Number
I have no DEA registration number
Leave this field blank
We value your privacy. To view our privacy policy please
Click here
.
