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Infusion Services Support

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Complete this form for timely help with your Walgreens infusion services question(s) or comment(s).

To: Walgreens | Subject: Pharmacy & Health › Infusion Services › Infusion Services Support

All fields are required unless otherwise indicated.

Note: Please do not submit confidential or sensitive information such as medical or prescription information, refill requests, social security numbers, or credit card numbers on this form.

Your contact information

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*It may be necessary in some cases for Customer Service to contact the customer in order to complete a request.

First Name:

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Email Address:

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Disclaimer: Entering your email will opt you out of ALL accounts associated with this email. If you have multiple accounts with this email and wish to opt out of only select accounts, please call 1-877-250-5823.

We will email you back within one business day. If your question is clinical, we will have a pharmacist call you back.

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Screen name:

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Telephone:

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Any clinical questions will require a phone number for the pharmacist to contact you.

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Please type your 10-digit phone number in this format: 5551234444.

Is it OK to leave a message at this number?

Yes

Order Number:

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Address:

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City:

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State:

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ZIP Code:

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DOB:

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Member Id:

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Current role

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Product information

Product Name:

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UPC Number:

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Order Number

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Card Information

Type of card

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Estimated Purchase Date:

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Store Information

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Date of Visit:

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Time of Visit:

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Employee Name

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Primary Cardholder information

I am the Primary Cardholder

First Name:

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Last Name:

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Employer

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Member ID:

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Group Number:

(Optional)

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RxBIN:

Please enter your Rx BIN.

Please enter a valid RXBin. Your answer can only contain letters and/or numbers.

RxPCN:

Please enter your Rx Processor Control Number.

Please enter a valid RXPCN. Your answer can only contain letters and/or numbers.

Input Code

(Optional)

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Please select a store

We welcome your comments and feedback. However, please remember any message or other communication sent to Walgreen Co. becomes the exclusive intellectual property of Walgreen Co. and does not entitle the author to any form of compensation.

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Infusion Services Support

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Card Information

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