nPEP Registration Form

Registration and proof of licensure is required to participate in the nPEP dispensing program. Confirmation of registration may take 7-10 business days, but can be expedited by uploading an image of the training certificate.

Please complete the registration form below.

Thank you!

Submission Date

Title

First Name

* must provide value

Middle Name or Initial

Last Name

* must provide value

Suffix

NPI Number

Pharmacist License Number

* must provide value

Image of License

Upload file

Contact Number

* must provide value

Email Address

Confirmation of training and registration may take 7-10 business days. To expedite your registration and confirmation of training, please upload your certificate of training completion here.

If you have any difficulty please contact MDH Pathways to Prevention at mdh.pathwaystoprevention@maryland.gov

Upload file

Facility Name

* must provide value

Facility Name

* must provide value

Facility Street Address

* must provide value

Facility Street Address 2

Facility City

* must provide value

Facility Zip Code

* must provide value

Facility Phone Number

* must provide value

Facility Hours and Days of Operation

* must provide value

Do you intend to dispense nPEP at this practice location? You will be listed in our nPEP pharmacist directory if you select yes.

* must provide value

Yes

reset

Do you have more than one practice location where you intend to dispense nPEP?

* must provide value

Yes

reset

Facility Street Address

* must provide value

Facility Street Address 2

Facility City

* must provide value

Facility Zip Code

* must provide value

Facility Phone Number

* must provide value

Facility Hours and Days of Operation

* must provide value

Do you have any additional practice locations where you intend to dispense nPEP?

* must provide value

Yes

reset

Please list the facility name, address, phone number, and hours of operation:

* must provide value

Expand

Is there more than one pharmacist at any of your practice locations?

* must provide value

Yes

reset

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