New OPA Profile

Basic Contact Information

Please use this form to update any information.

First Middle Last
Suffix
OH Pharmacist License #
(If you are not a pharmacist, or not licensed in Ohio, please place "N/A", or the state in which you are licensed, in the "OH Pharmacist License #" field above.)
Preferred Email
(This is the email address that will be used to contact you for all OPA email communications including legislative updates, programming information and other important OPA e-bulletins.)

Work Address and Information

Work Title
Company Name
Address
City State Zip
Work Phone Fax
Toll-Free

Home Address

Address
City State Zip
Home Phone Mobile

Primary Address

Please indicate ONE Primary address to which you wish to receive all OPA mailings.
Primary Address WORK Address is Primary Address
HOME Address is Primary Address

Additional Information

College Attending/Attended
Graduation Year
R.Ph PharmD Additional (Degree or Certification)
Employment Type
Practice Setting
   - denotes required fields