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Join ConnectBH

Pharmacies join and participate at no cost. Review the Participation Agreement below and complete the form to begin onboarding.

ConnectBH Pharmacy Participation Agreement

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Legal Pharmacy Name *

DBA / Store Name

Address Line 1 *

Address Line 2

City *

State *

ZIP *

Phone *

Primary Pharmacy Email *

NPI *

Tax ID (EIN)

Pharmacy Management System (optional)

Partner Code (if available)

Website (if available)

Signer Full Name *

Title / Role *

Signer Email *

Typed Signature (type full name) *

I certify that I am authorized to bind this pharmacy and agree to the ConnectBH Pharmacy Participation Agreement.