Washington > Statewide > Department Of Health
Pharmacy License Application DOH 690-152 - Washington
| Pharmacy License Application Form. This is a Washington form and can be used in Department Of Health Statewide . |
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Pharmacy License Application Packet Contents: 1. 690-159 ..... Contents List/Mailing Information ..................................................1 page 2. 690-160 ..... Application Instructions Checklist ................................................2 pages 3. 690-152 ..... Pharmacy License Application .....................................................3 pages 4. 690-249 ..... NPLEx Account Activation ...........................................................2 pages 5. 690-222 ..... NPLEx Exception Request ..........................................................2 pages 6. RCW/WAC and Online Web Site Links .............................................................1 page In order to process your request: Mail your application with initial documentation and your check or money order payable to: Department of Health PO Box 1099 Olympia, WA 98507-1099 Send other documents not sent with initial application to: Board of Pharmacy Credentialing PO Box 47877 Olympia, WA 98504-7877 Contact us: 360.236.4700 DOH 690-159 June 2012 (This page intentionally left blank.) American LegalNet, Inc. www.FormsWorkFlow.com Application Instructions Checklist When your application for pharmacy license is received by the Department of Health, you will be notified in writing of any outstanding documentation needed to complete the application process. Indicate type of application--New, change of ownership, change of location, or name change. · New--First time requesting a pharmacy license. · Change of Ownership--When name of legal owner/operator changes resulting from the sale of licensed pharmacy. · Change of Location--Changing the location address of the pharmacy. Include your current license number. · Name Change Only--List your current facility name. F Check One: Please check your legal owner/operator business structure type according to your Washington State Master Business License. Application Fees: Check all that apply; pharmacy location, controlled substance act, ancillary utilization (complete additional application), or differential hours (complete additional application). Fees are non-refundable. You can check the online fee page for current fees. Note: If you are applying for ancillary utilization you have to complete the ancillary plan and send it in with the application. 1. Demographic Information: UniformBusinessIdentifierNumber(UBI#):Enter your Washington State UBI #. All Washington State businesses must have UBI #'s. City, county, and state government departments also have UBI#'s. FederalIDNumber(FEIN#):Enter your Federal ID Number, if the business has been issued one. Legal Owner/Operator Name: Enter the owner's name as it appears on the UBI/ Master Business License. Mailing Address: Enter the owner's complete mailing address. Phone and Fax Numbers: Enter the owner's phone and fax number. EmailandWebAddress:Enter the owner's email and agency Web addresses, if they have them. Facility/Agency Name: Enter the agency's name as advertised on signs, brochures or Web sites. Physical Address: Enter the agency's physical street location including city, state, zip code, and county. DOH 690-160 June 2012 Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com F F Emailaddress:Enter the agency's email address if available. Phone and Fax Numbers: Enter the agency's phone and fax number. Mailing Address: Enter the agency's mailing address, if different than physical address. F 2. Facility Information: Type of Pharmacy: Please check which type of pharmacy you are applying for; community retail, hospital, jail, long-term care, mail-order, nuclear, parenteral, or internet (include web address) Hours Pharmacy will be open: Enter hours pharmacy will be open MondayFriday, Saturday, Sunday, and any holiday hours that will be open. DrugEnforcementAdministration(DEA)RegistrationNumber: Enter the federal DEA registration number if dispensing controlled substances. Enter "pending" if the pharmacy has not been issued its DEA registration number. Background Questions: Check yes or no and if you check yes, list and explain on a separate sheet of paper. Pharmacist in Charge: Enter pharmacist name, license number, and date of appointment. F F 3. Contact Information: Enter name, title, phone number, fax number, and email address. 4. Additional Information: Corporation information: Enter date of incorporation, corporate number, and state of corporation. Legal Owner: List the names, titles, addresses, and phone numbers of the corporate officers, partners, members, and managers. Attach additional completed pages if you need more space. Change of Ownership Information: List the previous legal owner name, previous name of facility, previous license number, and effective date of ownership change. List of Pharmacists: List all pharmacists working in your pharmacy. Attach additional completed pages if you need more space. F Signature: Signature of legal owner or authorized representative. Date signed. Print name of legal owner or authorized representative. Print title of legal owner or authorized representative. DOH 690-160 June 2012 Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Date Stamp Here Revenue: 0262010000 Fees (Check all that apply) F Pharmacy Location ................Fee F Controlled Substance Act .......Fee F Ancillary Utilization .................Fee (Complete additional application) F Differential Hours ...................Fee (Complete additional application) Check the online fee page for current fees All application fees are nonrefundable. Pharmacy License Application This is for: F New F Change of Ownership F Change of Location Current License # __________ F Name Change Only Current Facility Name ______________________________________ Check One F F F F F Association Corporation Federal Government Agency Limited Liability Company Limited Liability Partnership F F F F F Limited Partnership Municipality (City) Municipality (County) Non-Profit Corporation Partnership F F F F Sole Proprietor State Government Agency Tribal Government Agency Trust 1. Demographic Information UBI # Legal Owner/Operator Name Mailing Address City Phone (enter 10 digit #) Email Address State Zip Code County Federal Tax ID (FEIN) # Fax (enter 10 digit #) Web Address: Facility/Agency Name (Business name as advertised on signs or Web site) Physical Address City Facility Phone (enter 10 digit #) Email Address: Mailing Address (If different than physical address) City State Zip Code County State Zip Code County
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