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Pharmacy Licensure Application - District Of Columbia
| Pharmacy Licensure Application Form. This is a District Of Columbia form and can be used in Pharmaceutical Control Health And Licensing Administration Statewide . |
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GOVERNMENT OF THE DISTRICT OF COLUMBIA Department of Health Health Regulations and Licensing Administration Pharmaceutical Control 899 North Capitol St. 2nd floor Washington, D.C. 20002 FOR OFFICIAL USE ONLY! Application Complete: YES NO Approved Registration: YES NO FOR OFFICIAL USE ONLY! DATE: LIC/REG NO: INITIALS: PHARMACY LICENSURE APPLICATION RETURN COMPLETED APPLICATION WITH REGISTRATION FEE MADE OUT TO "D.C. TREASURER" TO 899 N. Capitol St, NE 2nd Floor, WASHINGTON, DC 20002 22 DCMR 1902.1 Licenses shall be issued for the following categories of pharmacies...except for nonresident pharmacies, which shall be required to register with the Department 22 DCMR 1902.2 A retail chain pharmacy with locations both in and outside of the District of Columbia (DC) shall obtain (a) a license for each location within DC and A registration pursuant of ยง1903 for each location outside DC CHECK ONE: CHECK ONE: CHECK ONE: Pharmacy Category DC Resident Pharmacy Nonresident Pharmacy Retail/Community Pharmacy (Biennial Registration Fee: $900) (Biennial Licensing Fee: $900) Nuclear Pharmacy Initial (Proposed date of opening ) Initial (Proposed date of opening _) Institutional Pharmacy Renewal (Registration No: ) _) Renewal (License No: Special or Limited Use Pharmacy Change of Ownership Change of Ownership Change of Pharmacy Name Nonresident Pharmacy Change of Pharmacy Name Change of Pharmacy Location Change of Pharmacy Location Change of Pharmacist-in-Charge Change of Pharmacist-in-Charge I. Changes to Current Pharmacy Status All pharmacies must report any change of ownership, name, location, or pharmacist-in-charge in writing to the Department CHANGE OF PHARMACY NAME CHANGE OF PHARMACY LOCATION CHANGE OF OWNERSHIP CHANGE PHARMACIST-IN-CHARGE Proposed Effective Date: Proposed Effective Date: Proposed Effective Date: Proposed Effective Date: Pharmacy License/Registration Number Pharmacy License/Registration Number Pharmacy License/Registration Number Pharmacy License/Registration Number New Pharmacist-in-Charge Name Previous Owner Name Previous Pharmacy Name Previous Pharmacy Address Pharmacist License Number New Owner Name New Pharmacy Name New Pharmacy Address Pharmacist Signature II. District of Columbia Resident Pharmacy Only (Complete this section then go to page 3) Pharmacy Street Address Pharmacy Name Area Code and Telephone Number Pharmacist-In-Charge (PIC) City State Zip Area Code and Fax Number PIC License Number Certificate of Occupancy Number (Please submit a copy of Certificate of Occupancy if this is an initial application) Expected Hours of Operation (Weekdays) Signature of PIC Current License Number, if applicable Expected Hours of Operations (Weekends/Holidays) Email Address 1 111024rxapplication.docx American LegalNet, Inc. www.FormsWorkFlow.com III. Nonresident Pharmacy Only Pharmacy Name Pharmacist-in-Charge (PIC) PLEASE WRITE THE REQUESTED INFORMATION AND SUBMIT LEGIBLE COPIES OF THE FOLLOWING: State of Licensure Certificate of Occupancy Number: Pharmacy Street Address PIC Pharmacy License Number (Submit copy of PIC pharmacy license) State Zip City Pharmacy License Number in resident state: Affidavit I certify that I have read and understand the pharmacy and drug laws and regulations of DC, and I have made the pharmacy and drug laws and regulations of DC available to all pharmacists working in the nonresident pharmacy Area Code and Telephone Number DEA Registration Number: Area Code and Fax Number Most recent pharmacy inspection report: Pharmacist-in-Charge Signature Toll-Free Telephone Number for Consultation 22 DCMR 1903.8(d)(4) List of Pharmacists practicing at this pharmacy check here if list is attached to the application Date 22 DCMR 1903.8(d)(5) List of resident agents located within DC designated to accept service of process check here if list is attached to the application Name Title 22 DCMR 1903.8(h) List of website address(es) and domain registration(s). check here if list is attached to the application Pharmacist name License Number Address Name Title Address Name Title Address IIIa. Please Answer the Following Questions 1. 2. Is the nonresident pharmacy's license, registration, or permit in good standing in the state in which it is located? Does the nonresident pharmacy have the ability to provide to the DC Department of Health ("Department") a record of prescription orders dispensed to a DC resident no later than three (3) business days after the time the Department requests the record? Is the nonresident pharmacy solely internet-based or operates primarily as an internet-based pharmacy? If "YES", please submit proof of: Certification by the Verified Internet Pharmacy Practice Site Program of the National Association of Boards of Pharmacy, or other national certification program for internet pharmacies for each website and domain registration Proof of registration in good standing in DC as a foreign corporation Does the nonresident pharmacy have a toll-free telephone number disclosed on a label affixed to each container of drugs or medical devices dispensed to patients in DC? PLEASE SUBMIT A COPY OF THE LABEL SHOWING THE TOLL-FREE NUMBER Is the nonresident pharmacy in compliance with the laws and regulations regarding confidentiality of prescription records in the state in which it is located, and if there are no such laws in that state, then is the pharmacy in compliance with the confidentiality laws and regulations of DC? YES YES NO NO 3. YES NO 4. YES NO 5. YES NO 2 111024rxapplication.docx American LegalNet, Inc. www.FormsWorkFlow.com IV. Proprietor Information Proprietor Type (CHECK ONE) INDIVIDUAL CORPORATION PARTNERSHIP UNINCORPORATED INDIVIDUAL OTHER: Name of Individual, Corporation, Partnership, Other NAME AND ADDRESS FOR PRINCIPAL OFFICERS Treasurer of Corporation/Partnership President of Corporation/Partnership Billing Street Address Vice President of Corporation/Partnership City State Zip Other Principal Corporate Officer Secretary of Corporation/Partnership State of Incorporation Year Incorporated Is the corporation in good standing with DC or the state of incorporation? YES NO Has any principal corporate officer ever been convicted of a felony involving drugs? YES NO If the answer to this is "YES", please submit a statement of explanation with this application V. Please Answer the Following Questions 1. Does your pharmacy facilitate the dispensing, shipping, mailing, delivery, or distribution of prescription drugs or devices from any jurisdict
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