User Registration | Pennsylvania PDMP System

License validation

Registration Tracking Id: {{registrationRequestId}}

Please enter your Pennsylvania professional license. License numbers begin with 2-3 letters. Example: MD123456L

Professional License Number *

Is the license {{enterLic}} already registered? *

Yes No

For security purposes, please confirm your date of birth and the last 4 digits of your social security number.

Date Of Birth *

Last 4 Digits Of Your SSN *

Is the role type a prescriber/ dispenser? *

Yes No

Based on your license, you are only eligible to register as a delegate of a prescriber or pharmacist. Are you trying to register as a delegate? *

Yes No

Create Login Credentials

Registration Tracking Id: {{registrationRequestId}}

Primary Email Address *

Secondary Email Address

Password *

Confirm Password *

Password must meet the following requirements:

Minimum of 8 characters
Contain one upper case letter
Contain one lower case letter
Contain at least one number
Contain one special character (! @ # $ etc.)
Maximum of 72 characters

How would you like to receive your auto generated password? *

Phone

Both

Note: Phone verification is optional here as you can verify the phone number in profile page after login. In case you want to receive message in phone then please verify your phone number before registration.

Verify Role Verify (Role and Supervisor Email)

Category *

Role *

Supervisor Email Address *

Basic Information

First Name *

Middle Name

Last Name *

Gender

Date Of Birth *

Last 4 Digits of Your SSN *

Cell Phone Number not verified verified

Password recovery requires a cell phone that receives text messages.

Address *

State *

City *

Other City Name *

ZIP Code *

Country

Professional Information

Please provide your DEA and NPI number.

License Number Additional license number (optional) *

Add

List of License numbers

Action	License Number	Expiry Date	Status
	{{x.license}}	{{x.led}}	{{x.message}}	{{x.message}}

DEA (Optional) *

Add

I do not have a DEA Number

List of DEA numbers

Action	DEA Number	Status
	{{x.dea}}	{{x.message}}	{{x.message}}

NPI (Optional) *

Add

List of NPI numbers

Action	NPI Number	Status
	{{x.npi}}	{{x.message}}	{{x.message}}

NCPDP

Employer Pharmacy Information

1. Employer Details Pharmacy Details

My employer address is the same address I entered above.

Employer Name Pharmacy Name *

Employer Phone Number Pharmacy Phone Number

Employer Address Pharmacy Address

Employer State Pharmacy State

Employer City Pharmacy City

Other City Name *

Employer ZIP Code Pharmacy ZIP Code

Employer License Number Pharmacy License Number * (if applicable)

Employer DEA Pharmacy DEA * (if applicable)

Employer NPI Pharmacy NPI (if applicable)

{{$index + 2}}. Employer Details Pharmacy Details

Employer Name Pharmacy Name *

Employer Phone Number Pharmacy Phone Number Must be in (000) 000-0000 format

Employer Address Pharmacy Address

Employer State Pharmacy State

Employer City Pharmacy City

Other City Name *

Employer Zip Code Pharmacy Zip Code

Employer License Number Pharmacy License Number *

Employer DEA Pharmacy DEA *

Employer NPI Pharmacy NPI (if applicable)

* I attest that the information I provided is my own and is true and accurate to the best of my knowledge.

* I agree to notify the PDMP if I begin prescribing or dispensing controlled substances in Pennsylvania in the future, so that I may gain access to query patients.

Type your name and today's date to electronically sign *

Electronic Sign *

Signature Date *

Do you have an active Pennsylvania professional license that permits you to prescribe or dispense medications? *

Are you registering as a delegate to query on behalf of a prescriber or pharmacist? *

Do you have a Pennsylvania professional license? *

Are you a prescriber or pharmacist working the Veterans Healthcare Administration? *

Which of the following best describes you? *

Do you have an active DEA number? *

Is there a possibility that you may prescribe a controlled substance to anyone in Pennsylvania, including immediate family members living in the same household? *

Which of the following best describes you? *

Which of the following best describes you? *

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Please enter your Pennsylvania professional license. License numbers begin with 2-3 letters. Example: MD123456L

Is the license {{enterLic}} already registered? *

For security purposes, please confirm your date of birth and the last 4 digits of your social security number.

Is the role type a prescriber/ dispenser? *

Based on your license, you are only eligible to register as a delegate of a prescriber or pharmacist. Are you trying to register as a delegate? *

{{msgCard2}}

Please enter the email address associated with the account of the prescriber or pharmacist you will be searching patients on behalf.

Please enter the email address associated with the account of the prescriber or pharmacist you will be searching patients on behalf of.

Please enter the DEA number of the pharmacy (or one pharmacy) that you will be submitting data for.

Password must meet the following requirements:

Verify Role Verify (Role and Supervisor Email)

Upload Id Proof *

Basic Information

Professional Information

Employer Pharmacy Information

1. Employer Details Pharmacy Details

{{$index + 2}}. Employer Details Pharmacy Details

Additional Information

The last name associated with the [DEA/NPI] does not match the last name on your Pennsylvania professional license. Are you sure it is correct? Or The [DEA/NPI] you provided is not valid. *

{{msgCard3}}

Please choose a option to verify identity *

Please choose a option to verify identity *

{{step4msgSec}}

PDMP Registration

Do you have an active Pennsylvania professional license that permits you to prescribe or dispense medications? *

Are you registering as a delegate to query on behalf of a prescriber or pharmacist? *

Do you have a Pennsylvania professional license? *

Are you a prescriber or pharmacist working the Veterans Healthcare Administration? *

Which of the following best describes you? *

Do you have an active DEA number? *

Is there a possibility that you may prescribe a controlled substance to anyone in Pennsylvania, including immediate family members living in the same household? *

Which of the following best describes you? *

Which of the following best describes you? *

{{msgCard}}

Please enter your Pennsylvania professional license. License numbers begin with 2-3 letters. Example: MD123456L

Is the license {{enterLic}} already registered? *

For security purposes, please confirm your date of birth and the last 4 digits of your social security number.

Is the role type a prescriber/ dispenser? *

Based on your license, you are only eligible to register as a delegate of a prescriber or pharmacist. Are you trying to register as a delegate? *

{{msgCard2}}

Please enter the email address associated with the account of the prescriber or pharmacist you will be searching patients on behalf.

Please enter the email address associated with the account of the prescriber or pharmacist you will be searching patients on behalf of.

Please enter the DEA number of the pharmacy (or one pharmacy) that you will be submitting data for.

Password must meet the following requirements:

Verify Role Verify (Role and Supervisor Email)

Upload Id Proof *

Basic Information

Professional Information

Employer Pharmacy Information

1. Employer Details Pharmacy Details

{{$index + 2}}. Employer Details Pharmacy Details

Additional Information

The last name associated with the [DEA/NPI] does not match the last name on your Pennsylvania professional license. Are you sure it is correct? Or The [DEA/NPI] you provided is not valid. *

{{msgCard3}}

Please choose a option to verify identity *

Please choose a option to verify identity *

{{step4msgSec}}