Mississippi > Statewide > Board Of Pharmacy
Application For Non-Resident Pharmacy Permit - Mississippi
| Application For Non-Resident Pharmacy Permit Form. This is a Mississippi form and can be used in Board Of Pharmacy Statewide . |
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204 Key Drive Suite D Madison, MS 39110 Office: 601-605-5388 Street Address: P.O. Box 24507 Jackson, MS 39225-4507 Mailing Address: Fax: 601-605-9546 APPLICATION FOR NON-RESIDENT PHARMACY PERMIT January 1, 2012 - December 31, 2013 FEE - $300.00 Business Name: Street Address: Mailing Address City, State, Zip: County: e-mail address: Web Address: Fax: Telephone: Principle Pharmacy Owner(s) or officers if Corporation: (Attach list if necessary) (Address) (Address) (E-mail) (E-mail) (Name) (Name) Briefly describe all pharmacy services conducted by your facility. List all companies you are contracted with, such as a Pharmacy Benefit Manager (PBM), or any other organizations that administer or process your transactions-if applicable. Does your facility host one or more internet websites? [ ]YES If yes, list each web address hosted by your facility. If applicable, describe in detail all internet pharmacy services. [ ]NO Attach a copy of your facility's most recent inspection report conducted by the State Board of Pharmacy in your state. Name typed or printed Date: _____________________ PHARMACY PERMIT NUMBER:____________ DATE ISSUED:___________________________ Pharmacist's signature Mississippi License Number OFFICE USE ONLY FILE NUMBER:_____________________ RECEIPT NUMBER:_________________ American LegalNet, Inc. www.FormsWorkFlow.com Miss. Code Ann. § 73-21-106 MISSISSIPPI CODE of 1972 *** Current through the 2010 2nd Extraordinary Session *** TITLE 73. PROFESSIONS AND VOCATIONS CHAPTER 21. PHARMACISTS MISSISSIPPI PHARMACY PRACTICE ACT Miss. Code Ann. § 73-21-106 (2011) § 73-21-106. Registration requirement for nonresident pharmacies that ship, mail, or deliver drugs into state [Repealed effective July 1, 2011] (1) Any pharmacy located outside this state that ships, mails or delivers, in any manner, controlled substances or prescription or legend drugs or devices into this state shall be considered a nonresident pharmacy, shall be registered with the board, and shall: (a) Disclose to the board the location, names, and titles of all principal corporate officers and all pharmacists-in-charge. A report containing this information shall be made on an annual basis and within thirty (30) days after any change of office, corporate officer or pharmacist-in-charge; (b) Comply with all lawful directions and requests for information from the regulatory or licensing agency of the state in which it is licensed as well as with all requests for information made by the board pursuant to this section. The nonresident pharmacy shall maintain at all times a valid unexpired license, permit or registration to conduct the pharmacy in compliance with the laws of the state in which it is a resident. As a prerequisite to registering with the board, the nonresident pharmacy shall submit a copy of the most recent inspection report resulting from an inspection conducted by the regulatory or licensing agency of the state in which it is located; and (c) Maintain its records of controlled substances and prescription or legend drugs or devices dispensed to patients in this state so that the records are readily retrievable from the records of other drugs dispensed. (2) Any pharmacy subject to this section shall provide during its regular hours of operation, but not less than six (6) days per week and for a minimum of forty (40) hours per week, a toll-free telephone service to facilitate communication between patients in this state and a pharmacist at the pharmacy who has access to the patient's records. This toll-free number shall be disclosed on a label affixed to each container of drugs dispensed to patients in this state. (3) The registration fee for nonresident pharmacies shall be the same as the fee as set by subsection (4) of Section 73-21-105. (4) The registration requirements of this section shall apply to any nonresident pharmacy that dispenses, distributes, ships, mails or delivers controlled substances or prescription or legend drugs and devices into this state directly to a consumer. (5) The board may deny, revoke or suspend a nonresident pharmacy registration only for: American LegalNet, Inc. www.FormsWorkFlow.com (a) Failure to comply with any requirement of this section; (b) Conduct that causes serious bodily or serious psychological injury to a resident of this state if the board has referred the matter to the regulatory or licensing agency in the state in which the pharmacy is located and the regulatory or licensing agency fails to initiate an investigation within forty-five (45) days of the referral; or (c) Violation of the Uniform Controlled Substances Law. (6) It is unlawful for any nonresident pharmacy that is not registered under this section to advertise its services in this state, or for any person who is a resident of this state to advertise the pharmacy services of a nonresident pharmacy that has not registered with the board, with the knowledge that the advertisement will or is likely to induce members of the public in this state to use the pharmacy to fill prescriptions. (7) When requested to do so by the board or the Mississippi Bureau of Narcotics, each nonresident pharmacy shall supply any inspection reports, controlled substances dispensing records, warning notices, notice of deficiency reports or any other related reports from the state in which it is located concerning the operation of a nonresident pharmacy for review of compliance with state and federal drug laws. HISTORY: SOURCES: Laws, 1994, ch. 513, § 9; Laws, 2009, ch. 469, § 2, eff from and after July 1, 2009. American LegalNet, Inc. www.FormsWorkFlow.com
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