Easy Copay

Pharmacy Registration

It will only take a couple minutes to fill in the information we need to get your pharmacy registered.

Once you have filled out this registration form you will receive an email with your username and password, you will also be contacted within the next 24-48 hours by a member of our support team to verify your information and complete your registration.

Thank you for taking the time to register for FSAok AutoCoPay.

Pharmacy Info

NPI#
NCPDP#
DEA#
  10 digits   7 digits   9 digits
Legal Name
DBA Name
Tax ID Entity
Phone Number Ext  
Fax Number
Website Address
Email Address
Active Status InActive


Street Address

Address 1
Address 2
City- State
Zip Code (+4) -

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