Category(s) of Service:
0441 - Freestanding - Pharmacy only, OR
0442 - Freestanding - Pharmacy-based DME
* Pharmacy-based DME (0442) can only be enrolled with a Pharmacy (0441). Pharmacy 0441 can enroll without the Pharmacy DME (0442).

If you are ALREADY ENROLLED and need to change your address,

Provider Index > Pharmacy > Freestanding

Provider Enrollment & Maintenance Instructions

Freestanding
Prior to completing the Enrollment Form, determine if your pharmacy meets basic criteria for enrollment by using the Pharmacy Primary Screening Form. This form must be included with all other forms for consideration for your enrollment.

Complete Enrollment in PSP if you are:

Applying for initial ENROLLMENT or ALREADY ENROLLED and enrolling another NPI, or
Responding to a letter instructing you to REVALIDATE your enrollment, or
Seeking REINSTATEMENT or REACTIVATION of your previous enrollment, or
Reporting an OWNERSHIP CHANGE

PSP Login

If you have any questions or need assistance with your application, please contact the eMedNY Call Center at 1-800-343-9000 or click here to send us an email. Please note, the Medicaid Pending Provider Listing lists all applications that are in process, and the Medicaid Enrolled Provider Listing lists all enrollments that have been approved.

General Instructions for Enrollment in PSP
- Each field is identified as mandatory or optional.
- Incomplete applications can be saved at any time and returned to later for modification or completion as long as the application status is "In Process."
- Providers can upload required documentation (as outlined below).
- Valid telephone numbers are required for each service address.
- Once all required information has been entered and documentation has been uploaded, the application should be reviewed for accuracy, and submitted to the State for review.
Click here to begin
Requirements & Additional Forms
PLEASE NOTE: Only complete applications containing all requirements and additional forms will be accepted for processing. Applications with missing or incomplete information will be rejected and returned
- Application Fee ($750)
  Medicare enrollment is required for Pharmacy enrollment in Medicaid.
- Application Fee Exemption
- DEA Form Completion is required, failure to complete this form may cause your application to be rejected and returned.
- Electronic Funds Transfer (EFT) Authorization (NOT REQUIRED for revalidation if EFT is already in place and no change is requested)
- ETIN Certification Statement (For new enrollment, i.e., never enrolled)
- Hospital, Nursing Home, Clinic Based Pharmacy Questionnaire
- Out of State Pharmacy Application
- Personal Identification Number (PIN) Request
- Pharmacy Information Request For new enrollment and reinstatement only. Be sure to submit the additional documentation requested on this form. Note, this form is not required for revalidation.
- Pharmacy Primary Screening Prior to completing the Enrollment Form, determine if your pharmacy meets basic criteria for enrollment by using the Pharmacy Primary Screening Form. This form must be included with all other forms for consideration for your enrollment, revalidation, or reinstatement.
- Prior Conduct Questionnaire If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
- Request for Pharmacy Medicare Enrollment Exemption Completion is required. Failure to complete this form will cause your application to be rejected and returned.
- Supervising Pharmacist Agreement (for your Medicaid-enrolled Supervising Pharmacist)
- DEA Certificate Copy of your DEA certificate or web based printout from the office of Diversion Control website at https://www.deadiversion.usdoj.gov/webforms/dupeCertLogin.jsp. Note: Completion of the DEA Form 610301, is also required.
- For Changes of Ownership ONLY Provide proof that a Change of Ownership has occurred. Examples of proof include but are not limited to a Bill of Sale, Transfer of Ownership, Operating Agreement, Stock Purchase Agreement, etc.
- For out of State Pharmacies Only:
  1,    Complete Form 402101, and
  2.     DMEPOS Competitive Bid/Contract Suppliers should include Proof of Contract Supplier Status
- IRS Assignment Letter indicating the FEIN and Applicant Name on the Enrollment Form (W-9 NOT ACCEPTABLE). IRS Assignment Letter (Form: SS-4) can be obtained by going to IRS.Gov or call IRS at 1-800-829-4933
- Medicare Enrollment is Required prior to applying for Medicaid enrollment
- Medicare enrollment is required prior to applying for Medicaid enrollment: If the pharmacy is applying for or enrolled in Medicaid category of service 0441, Medicare enrollment is required. Please compete the Request for Pharmacy Medicare Enrollment Exemption and submit with your application. To enroll in Medicare, visit: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/Enrollment-Applications. Do not submit Medicare enrollment forms with your NYS application.
- New York State Board of Pharmacy Certificate
Provider Compliance Certification - Certification of a Provider Compliance Program may be required. By signing the Certification Statement for Provider Billing Medicaid, form EMEDNY-490602 (i.e., ETIN for providers who have never been enrolled) or the Certification Statement for Provider Billing Medicaid, form EMEDNY-490601 (i.e., ETIN for providers seeking reinstatement), you (or the entity) certify that, where required, you (or the entity) have adopted and implemented an effective compliance program pursuant to New York State Social Services Law section 363-d, and have satisfied the requirements of Title 18 of the New York Code, Rules and Regulations Part 521. For more information on the Provider Compliance Program, please go to the program website at https://omig.ny.gov/compliance/compliance.

Maintenance Forms

Change of Address
DEA Form Completion is required, failure to complete this form may cause your application to be rejected and returned.
Disclosure Form for Businesses
EFT Attestation Form
Personal Identification Number (PIN) Request
Prior Conduct Questionnaire If you answer "Yes" to questions 1-4 in section 6 of the enrollment application, you must complete this form. Note: If upon Department review of your application an exclusion is found, you will be required to complete this form.
Request for Pharmacy Medicare Enrollment Exemption Completion is required. Failure to complete this form will cause your application to be rejected and returned.
Status Change Form for Businesses This form is to be used when a pharmacy wishes to voluntarily terminate their New York State Medicaid enrollment
Supervising Pharmacist Agreement (for your Medicaid-enrolled Supervising Pharmacist)

Last Updated: 10/2025

Supplemental Information