Independent Pharmacy Questionnaire Instructions

Thanks in advance for completing the TopRx Independent Pharmacy questionnaire. The questionnaire should be completed by qualified personnel (Owner, Pharmacist in Charge, Designated Representative, etc.). Prior to starting the questionnaire please be sure to have the following information available for reference:

· Current license information including the DEA license, State Board of Pharmacy license and the State Controlled Substance License (if applicable)

· Current license information for employees including the Pharmacist-in-Charge (PIC) and any other licensed individuals

· Number of prescriptions filled daily

· Percentage of controlled substance prescriptions filled daily

· Percentage of cash sales monthly

· Top 5 physicians who write controlled substances and their DEA numbers

At the end of the questionnaire there will be a button. Once you submit your responses, you will not be able to go back to make any changes.

If you would like to purchase CII’s through CV’s, in addition to the Questionnaire, you will also be required to provide a Current 90-day Drug Usage Report with NDC’s, and total Qty dispensed in those 90 days of all products dispensed. (Controls, legends and OTC’s) Preferably in an Excel format. The Current 90-day Usage Report must have Name and address of the Pharmacy and the current 90-day date range displayed at the top of the page. The Usage report must be a summarized report. NDC# should only appear once with the total units dispensed over the current 90 days.


· Name & Address of Pharmacy
· Current 90-day date range
· All drugs dispensed ( Controls, Legend, OTC’s )
· Summarized ( NDC# should only appear once with total qty dispensed )
· Excel format preferred

Depending upon the answers to some of the questions, you may be asked to submit additional information such as a Business Model, pictures of your facility, or Standard Operating Procedures for Suspicious Order Monitoring.

Once finished, a confirmation with a big green will be displayed stating: "Thank you. Your questionnaire is complete."

If you do not receive a confirmation, then the questionnaire was not submitted.

After successfully submitting the questionnaire, you will be given the option to print a summary of your responses for your records.

If you have any questions regarding this questionnaire, please contact your Account Manager or call Customer Service at 901-373-9314.