add pharmacy data to PA request

using select2 gem for prettier CSS
This might be a bug:

```javascript
.select2('data').text
```

I think `text` is a function, so you would need `text()`. 

I could be wrong though.  I'm going off of the [select2 website](http://ivaynberg.github.io/select2/) and running:

```javascript
$('#select2-drop-mask').select2('data').text()  // => ""
$('#select2-drop-mask').select2('data').text    // => function (a){if(f.isFunction(a))return ...
```