Prescription Monitoring Program: Pharmacist Registration

Please complete and submit the following form. We will use the information to verify your identity and the authenticity of your access request. We will contact you by e-mail. License status will be verified by using the applicable state's professional license lookup services. Submitted information will remain confidential.

Note: The E-mail address is not your Username. Your Username will be sent to you in an E-mail once your account has been activated.

Your username will be sent to you in an email once your account has been activated.

Pharmacy Information
All communications will be sent to this email address, including information that will help you recover your ID or password.
Please enter your email address again to help ensure accuracy.
8 to 18 characters with at least 1 number and 1 upper and lower case letters. Do NOT use your email password.
() - -
Enter in any format, the day and time we would most likely be able to reach you by phone at your pharmacy.
Pharmacist Information
ex: 051 456789
If you don't have one, leave blank.

If you select "I do not agree", please contact (217) 524-1311.