NY Medicaid  
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ENROLLMENT FORM

Category(s) of Service:
0441 - Freestanding - Pharmacy only, OR
0442 - Freestanding - Pharmacy-based DME
* Pharmacy-based DME (0442) can only be enrolled with a Pharmacy (0441). Pharmacy 0441 can enroll without the Pharmacy DME (0442).


If you are ALREADY ENROLLED and need to change your address, click here.

  Application Fee is REQUIRED. Click here for more information.  


Print Instructions

Provider Index > Pharmacy > Freestanding

Provider Enrollment & Maintenance


Freestanding
Prior to completing the Enrollment Form, determine if your pharmacy meets basic criteria for enrollment by using the Pharmacy Primary Screening Form. This form must be included with all other forms for consideration for your enrollment.


Complete this Enrollment Form if you are:
  1. Applying for initial ENROLLMENT or ALREADY ENROLLED and enrolling another NPI, or
  2. Responding to a letter instructing you to REVALIDATE your enrollment, or
  3. Seeking REINSTATEMENT or REACTIVATION of your previous enrollment, or
  4. Reporting an OWNERSHIP CHANGE

BUSINESS Enrollment Form

If you have any questions or need assistance with your application, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email. Please note, the Medicaid Pending Provider Listing lists all applications that are in process, and the Medicaid Enrolled Provider Listing lists all enrollments that have been approved.
Last Updated: 5/2024


Supplemental Information

033-7:32:37 PM