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Location Change Form

AdvantageTrust Member Services Phone:  (866) 841-2992
AdvantageTrust Member Services Fax: (847) 592-7801
AdvantageTrust Member Services email: atmembership@advantagetrustpg.com
Please complete the information below:

*indicates required field
Name of Person Requesting Change:
Title of Person Requesting Change:
Your E-mail Address: *
Current Facility Name:
Current Facility Address:
Current Facility City
Current Facility State
Current Facility Zip
GPOID:
COID:
Would you like your facility to be added to the pharmacy program?
(If yes, please complete Section 2 below)  


1 What is the NEW facility Name?
Organization Legal Name
Doing Business as Name
2 If physician office/clinic:
Who is the physician that you would like rostered?
(Note: The DEA certificate for the rostered physician must exactly match the shipping address of the facility.)
Primary Provider First Name
Primary Provider Last Name
Federal DEA Certificate Number
Federal DEA Certificate Expiration Date
(Administrative centers skip section 2.)
3 What is NEW facility shipping address?
Shipping Address (with Suite #)
Shipping City:
Shipping State  
Shipping Zip
4 Who is the NEW contact at
your facility?
Purchasing Contact Name
Purchasing Contact Title
Purchasing Contact Phone
Purchasing Contact Fax
Purchasing Contact E-mail
5 Comments:
Comments

6		 Please submit your request for processing. 
Note: This change can take 2-3 weeks to appear on the HealthTrust roster.