Form 1340, Pharmacy Enrollment Application

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Effective Date
1340.pdf (189.81 KB)



Updated: 4/2020



For pharmacies to enroll with the Texas Vendor Drug Program.

Detailed Instructions

  • Pharmacy staff must complete all fields that are applicable to your pharmacy type.
  • The Pharmacy Provider Enrollment Application and the Pharmacy Provider Enrollment Agreement (HHS Form 1341) are completed and submitted at the same time.
  • Full instructions are available at the Texas Vendor Drug Program website


  • Fax: 512-730-7477
  • Mail: Vendor Drug Program (Mail Code 2250)
             Texas Health and Human Services
             4900 North Lamar Blvd.
             Austin, TX 78751


Questions about this form should be sent by email to