MTM ConnectionsTM

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SUBMIT PHARMACIST PROFILE
Important Notice:  To maintain an individual pharmacist profile on this web site you must be a pharmacist member of APhA.  If you are not currently an APhA member, please visit www.pharmacist.com to submit a new member application or to reinstate your past membership.  Your membership will be verified prior to your profile being activated and subsequently included in search results on the MTM Locator.  APhA and AMCP also reserve the right to notify you that your profile may be deactivated at any time if your membership lapses or your profile is considered to be inaccurate, inappropriate or incomplete.  When completing your profile please note that any field marked with an asterisk is required information.

APhA Member ID     Select box if new member awaiting member ID.
Profile User ID and Password
 To maintain your profile on the MTM Locator you will need to create a User ID and password to prevent others from altering your profile and allow you to edit and update your profile as required.  Neither the User ID or password are case sensitive but they must be more than 6 and a maximum of 8 alpha or numeric characters.
Enter a User ID*   Enter a Password*
 
Provider Contact Information    
First Name* Last Name*
 
Business Address Line 1* Business Address Line 2
 
Business City* State* Zip Code*
 
Business Telephone* Business or Preferred E-mail Address*
 
Business Name (optional) Business Web URL (optional)
 
Services Offered and Capabilities
Patient Care Services
(Select all that apply)		 National MTM Network Participation
(Select all that apply)
Comprehensive  medication review
Targeted medication review
Medication adherence
Medication reconciliation
Anticoagulation monitoring
Asthma/COPD
Bone disease/Arthritis)
Diabetes
Heart failure
Immunization administration
Hyperlipidemia
Lifestyle/Wellness
Mental health
Pain therapy
Pharmacokinetic monitoring
Other (list in additional information section)		 None as listed below.
 MedManagementTM
Med PathfinderTM
PharmMDTM
MirixaTM
 Outcomes Pharmaceutical Health CareTM
Other (list in additional information section)
Documentation and Billing Systems
(Select all that apply)
None as listed below.
 Payer specified web-based system
Self-maintained electronic health record system
Shared access to electronic health record system
On-site paper-based files
Integrated with pharmacy dispensing system
Other  (list in additional information section)
Service Delivery Methods
(Select all that apply)
Service Delivery Locations
(Select all that apply)		 In-person
Telephonic
Tele-video
Web-based
Mailings/Print
Other (list in additional information section)
Pharmacy practice office
 Telephonic
 Televideo / Web conferencing
 In patient's home/location
 Medical clinic or ambulatory care site  
Other (list in additional information section)
Provider Qualifications
Certifications or Residency Training
(Select all that apply)		 Board of Pharmaceutical Specialties Certification
(Select all that apply)
None as listed below.
 Certified diabetes educator (CDE)
Certified asthma educator (CAE)
Certified geriatric pharmacist (CGP)
PGY1 residency training completed
PGY2 residency training completed
Other (list in additional information section)		 None as listed below.
 Pharmacotherapy
 Pharmacotherapy with infectious disease
 Pharmacotherapy with cardiology
 Nutrition support
 Psychiatry
 Nuclear
 Oncology
 Ambulatory Care (effective 2011)
Patient Care Certificate Programs Completed
(Select all that apply)		 Pharmacist Education and Licensure
(Select all that apply)
None as listed below. 
Medication therapy management
 Immunizations
 Diabetes
 Lipid management
 Smoking cessation counseling
Other (list in additional information section)		  

BSPharm
PharmD
  Year graduated with highest degree.
  
 States where current active pharmacist licensure.

Additional Information (optional)