Community Pharmacy All Hazards Dispensing Program

Please complete and submit the form below to sign up as a community pharmacy partner for the All Hazards Dispensing program.

As a committed community partner, your pharmacy will help ensure that the public is protected. Your pharmacists and pharmacy staff will serve as experts in the area of dispensing medications and administering vaccines safely and efficiently in an emergency.

Community Pharmacy Partner Sign-Up Form

Community pharmacies that sign up as partners in this program will be compiled into a list of pharmacies that agree to support public health operations during an emergency. By completing and submitting this form, you are providing your consent to be listed (your business name and location) on the MPA website as an official community partner.

Listing this information will allow state and local public health departments know which community pharmacies wish to be contacted in an emergency to help with response activities.

If you represent a national community pharmacy chain, you may list your corporate address. Local health department emergency preparedness coordinators (LHD EPCs) can then contact any of your stores in their jurisdiction. If you are not a national chain, you may want to list all of your sites so that the LHD EPCs are able to recognize and contact the individual sites in other areas when needed. A printable form is also available online.

Community Pharmacy Partner Sign-Up Form

Pharmacy Name(Required)

Point of Contact for Your Store(s)(Required)

Address(Required)

Street Address Address Line 2 City State ZIP Code

All of our community pharmacy locations in Michigan are operating under this name/title.

Address 2

Street Address Address Line 2 City State ZIP Code

Address 3

Street Address Address Line 2 City State ZIP Code

Address 4

Street Address Address Line 2 City State ZIP Code

CAPTCHA

Phone

This field is for validation purposes and should be left unchanged.

Community Pharmacy All Hazards Dispensing Program: Partner Sign-up

Please complete and submit the form below to sign up as a community pharmacy partner for the All Hazards Dispensing program.

Community Pharmacy Partner Sign-Up Form

Community Pharmacy Partner Sign-Up Form

michigan pharmacists association