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PHP Pharmacy Request

Online Request For PHP Pharmacy Information

Please fill in the following form and press the Send My Request button to send your inquiry to a Pharmacy Services Representative. We will reply as soon as we have researched the issue/inquiry for you.

All information is required for us to process your request.

Provider Name:
Presbyterian Provider # or Tax ID #:
National Provider Identifier Number (NPI):
Provider Taxonomy Code:
Contact name:
Contact Phone: -
Email:
Member Name:
Presbyterian Member # or SS #:
Name of Drug Requested:

Formulary/Formulary Alternative:

Pharmacy Denials:

Pharmacy Exception:
Reason for Inquiry Request:
Attach Supporting Documentation:

File 1:

File 2:

File 3: