1 - Interest Form - Team Cuban Card & Cost Plus Drugs Affiliate Pharmacy Network

The survey will take approximately 4 minutes to complete. This form is only for US licensed pharmacists.

Thank you for your interest in our new Team Cuban Benefits Card. By completing the form below, you confirm that you are an independent pharmacist or independent pharmacy owner, and representing a retail, open door, brick and mortar pharmacy (or pharmacies), and interested in learning more about being a part of Team Cuban Card! By completing the information below on your pharmacy, you're signing up to hear more about our new project to bring transparent pricing to the masses near you and bring you new patients. Learn more at: www.teamcubancard.com. We will reach out to you soon. Thanks!
*****PLEASE NOTE: Hospital or institutional pharmacies and/or closed door mail order pharmacies - the Team Cuban Card is not a good fit for your pharmacy at this time.*****

-Mark Cuban Cost Plus Benefits, LLC

Let's Work Together!

Thank you for your interest in our new Team Cuban Benefits Card!

1. I have at least one retail, open door to the public, walk in pharmacy potentially for this program.
(PLEASE NOTE: This program is not for closed door, mail order, and/or hospital/institutional outpatient pharmacies at this time.)2. Is/are your outpatient retail open door walk in pharmacy or pharmacies affiliated with and/or owned by a healthcare or hospital system?3. Your Full name4. Phone number5. What state(s) is your pharmacy originally licensed as a pharmacy? (Your home state licenses, not any out of state licenses):6. Email address7. I am the ____ of the pharmacy(ies):8. Your pharmacy or pharmacies names and addresses:9. Tell us about your pharmacy (describe if you have walk in patients/open door pharmacy), the more details the better.10. If your pharmacy is located in TN, do you have 65,000 pharmacy claims or more per year?

Thank you! Your submission has been received!

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