Classic Pharmacy Delivery - Health & Wellness

Please submit this form for delivery of your prescription from Classic Pharmacy to Wagner College. A new prescription may need to be obtained from the Wagner College Center for Health and Wellness.

Classic Pharmacy

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

Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
Dorm Room
Email*
Phone*
Insurance Carrier*
i.e. Blue Cross Blue Shield, Cigna, Aetna, etc.
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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