Classic Pharmacy

Please submit this form and a copy of your insurance card so your prescription can be filled by Classic Pharmacy. A new prescription may need to be obtained from the Wagner College Center for Health and Wellness. All prescriptions will need to be picked up from Classic Pharmacy beginning March 12, 2020 until further notice.

This form will provide Wagner College and Classic Pharmacy with your Insurance information in order to fill your prescription.

Name*
First Last
Home Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
No Deliveries to Wagner College Campus until further notice.*
I agree to pick up my prescription.
Email*
Phone*
Name of Insurance Company*
Supply Insurance Company Prescription Card Information.
Insurance ID #*
Prescription Card BIN #*
Every Prescription Card has a BIN #. If there is not a BIN # then it is probably not your Prescription Card.
PCN #
Rx Group #
I understand that I must call Classic Pharmacy with my credit card information before my prescription order is processed.*
Classic Pharmacy: 718-727-0022
- Yes, I agree to call Classic Pharmacy.
Signature
Signature required upon delivery
Phone
This field is for validation purposes and should be left unchanged.

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