NY Medicaid  
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ENROLLMENT FORM

Category(s) of Service: 0444

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

  Application Fee is NOT Required  


Print Instructions

Provider Index > Supervising Pharmacist

Provider Enrollment & Maintenance



Enrollment required when employed by a freestanding pharmacy.


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

PRACTITIONER 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: 12/2021


Supplemental Information

032-7:21:04 PM