Pharmacy Online NDC Request

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Louisiana: NDC Request Form

Pharmacy Provider Information:

Pharmacy providers should use this form after receiving a claims rejection code stating "NDC PRICE MISSING, CALL MYERS & STAUFFER". Please do not include any personal health information (PHI) with submitted form or invoice.

Pharmacy Name:(Required)

NPI:(Required)

Address

City State / Province / Region ZIP / Postal Code Country

Phone:(Required)

Email:(Required)

Drug Information:

Drug Name and Strength:(Required)

National Drug Code (NDC):(Required)

Provider Cost Information:

Cost Per Package:(Required)

Package Size:(Required)

Date of Purchase:(Required)

Claim Information:

Dispense Date:(Required)

Quantity Dispensed:(Required)

Dispensing Fee:(Required)

Is this a new NDC?(Required)

Comments:

You must fax to (317) 571-8481 (Attention: Pharmacy Unit) or email lapharmacy@mslc.com copies of your purchase records that confirms your acquisition costs information. Once complete information is received, we will evaluate your inquiry and respond within 24 hours. For questions or to check the status of an inquiry, please contact us by email at lapharmacy@mslc.com or by phone at 800-591-1183.

Submitter's Name:(Required)

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