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Application For Louisiana Pharmacy Permit Located Out-Of-State - Louisiana
| Application For Louisiana Pharmacy Permit Located Out-Of-State Form. This is a Louisiana form and can be used in Board Of Pharmacy Statewide . |
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Louisiana Board of Pharmacy 3388 Brentwood Drive Baton Rouge, Louisiana 70809-1700 www.pharmacy.la.gov Application for Louisiana Pharmacy Permit Located Out-of-State Notices · Chapter 11 of the Board's rules enumerates the minimum requirements for pharmacies and prescription departments, and Chapter 23 identifies the additional requirements for non-resident or out-of-state pharmacies. All of our laws and rules may be accessed on our website, at www.pharmacy.la.gov. The Louisiana Board of Pharmacy requires compliance with current federal standards applicable to sterile compounding activities (USP Chapter 797). Pharmacies electing to engage in such activities for the benefit of Louisiana residents shall demonstrate their compliance with current federal standards by the attachment of appropriate documentation to their application. We encourage you to type your entries on the application. If you choose to print, please do so legibly using blue or black ink. Do not use pencil. Applications completed in pencil, or those with illegible entries, shall be returned to the applicant's designated contact person. Please do not re-format the application to accommodate your entries. Applications reformatted from the posted version shall be returned to the applicant's designated contact person. Please do not use entries such as "See attached"; an appropriate entry shall be made in each section. Incomplete applications shall be returned to the applicant's designated contact person. Blank applications may be copied as needed; please use standard copy paper. Applications completed or reproduced on thermal or waxy paper will not be accepted, and they shall be returned to the applicant's designated contact person. We encourage you to review your application and attachments prior to submission to the Board. Our experience shows the most common reason to return an application is for incomplete documents. This will only delay the processing of your application. The application shall be submitted to the Board office, at the address noted hereinabove, at least thirty (30) days prior to the anticipated opening date of the new pharmacy or the ownership transfer. Your application and fee will be valid for up to one year after the date of its receipt at the Board office. If the permit has not been issued by that date, the application shall be voided and the fee shall be forfeited. Pharmacy permits expire at midnight on December 31 of every calendar year, regardless of the date of issuance. Pharmacies may not operate with expired permits. · · · · · · · · · Form No. 52 Page 1 of 6 Rev 07-01-2011 American LegalNet, Inc. www.FormsWorkFlow.com Louisiana Board of Pharmacy 3388 Brentwood Drive Baton Rouge, Louisiana 70808-2537 Telephone 225.922.0852 ~ Facsimile 225.925.6499 Website: www.pharmacy.la.gov ~ Email: info@pharmacy.la.gov Application for Louisiana Pharmacy Permit Located Out-of-State (Complete this application for pharmacies located outside of Louisiana.) Please type all entries; if printing, please do so legibly using blue or black ink. All checks or money orders for the $175.00 fee shall be made payable to "Louisiana Board of Pharmacy." Mail this application, all attachments, and fee to the address noted at the top of this page. Incomplete applications will be returned to the contact person. Section 1 Reason for Application [select one] & Date of Opening _____ New Pharmacy Permit _____ Ownership Transfer Anticipated Date of Opening _______________________ Section 2 Pharmacy Information Name (d/b/a) _____________________________________________________________________________________________ Physical Address __________________________________________________________________________________________ City, Parish, State, ZIP _____________________________________________________________________________________ Telephone ___________________________ Facsimile ___________________________ Email __________________________ Toll-free Telephone ____________________________ Resident State Pharmacy Permit No. _________________ Expiration Date ____________________ DEA Registration No. _________________________ Expiration Date ______________________ Mailing Address __________________________________________________________________________________________ City, Parish, State, ZIP _____________________________________________________________________________________ Has this pharmacy ever been the subject of any disciplinary or other adverse action by any other licensing agency, or by any other government agency, or by any local, state, or federal law enforcement agency, or by any local, state, or federal court? _____ Yes _____ No If you answered "Yes" to this question, please attach a letter of explanation as well as a certified copy of the final disposition for each incident. If charges were dismissed, please provide a letter from the appropriate authority confirming dismissal of the charges. Your failure to disclose any prior disciplinary or adverse action or criminal history may result in the denial of this application or disciplinary action against the permit. Section 3 Applicant's Designated Contact Person [for processing of application] Name _________________________________________________________________________________________________ Company ______________________________________________________________________________________________ Address _______________________________________________________________________________________________ City, State, ZIP __________________________________________________________________________________________ Telephone _______________________ Facsimile ___________________ Email _____________________________________ For Board Use Only: Date application received: ____________________ Check / M.O. # __________________________ Amt. _________________ Interview Required: Yes / No Compliance Officer: ___________ Permit No. ____________ Issued: ___________ Form No. 52 Page 2 of 6 Rev 07-01-2011 American LegalNet, Inc. www.FormsWorkFlow.com Section 4 Pharmacy Ownership [select one] Please identify the legal entity which owns the pharmacy identified in Section 2. _____ Individual _____ Partnership _____ Corporation _____ LLC _____ Association _____ Government _____ Other [explain] Name: ________________________________________________________________________ Name: ________________________________________________________________________ Name: ____________________________________
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