WELCOME TO THE PRESCRIPTION DRUG REGISTRY REGISTRATION PROCESS

The below registration form should be completed by the person and/or organization who will be responsible for submitting prescription information to the Registry on the behalf of one or more pharmacies licensed in the State of Montana. Pharmacies will not be able to report information to the Registry until this form has been completed.

The below information must be provided for each pharmacy for which you are reporting.

Please complete the fields.

Submitter Information

Business Name:

Type of Business:

If other, what is your business type?

Preferred Method of Submission:

If uploading files through secure FTP (sFTP), you will need to supply the following information:

All IP addresses of machines which will be uploading to the service through sFTP.
A 4096-bit public key, suitable for SSH authentication, for authorization to our sFTP service.

This information can be sent to Montana Interactive via email at: PDRAssistance@egovmt.com

Contact Information

This person should be able to answer any questions about the pharmacy or pharmacies for which you are reporting. All fields are required.

First Name:

Last Name:

Phone: Extension Example: 406-555-1234, Ext: 97

Email Address: Example: example@example.com

Technical Contact Information (if different than above)

This person should be able to answer any questions regarding the technical details surrounding the file or file submission. If entering a technical contact, all fields are required.

First Name:

Last Name:

Phone: Extension Example: 406-555-1234, Ext: 97

Email Address: Example: example@example.com

Email Correspondence

Email Address:

NOTE: All correspondence and system notifications from the Prescription Drug Registry will be sent to this email address, including the summary details associated with your weekly report.

Please provide the following information for each pharmacy for which you will be reporting.

Pharmacies Entered so Far

Pharmacy Name	Contact Name	Action

Pharmacy

Note: the following information must be provided for each pharmacy for which you will be reporting. Click the "Add Pharmacy" button to add multiple pharmacies. All fields are required.

Pharmacy Name:

NOTE: Enter the pharmacy name exactly as it appears on your Montana license.

Montana License Number: Example: PHA-PHA-LIC-1234

DEA Number:

Pharmacy Contact First Name:

Pharmacy Contact Last Name:

Physical Address of Pharmacy

Address:

City:

State or Province:

Zip Code:

Pharmacy Contact Phone: Extension Example: 406-555-1234, Ext: 87

Pharmacy Contact Email: Example: example@example.com

Other Information

Please enter any additional information you wish to convey:

Should you have questions, or need assistance, please contact Montana Interactive via email at PDRAssistance@egovmt.com or by phone at 406-449-3468 extension zero.