New Pharmacy Permit Application

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(definition below) [ ] Yes [ ] No Does your pharmacy do compounding? [ ] Yes [ ] No If yes, does your pharmacy do sterile compounding? [ ] Yes [ ] No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lease send completed application and fee to: BBBBBBBBBBBBBBBBBBBBBBBBBBB 'DWH S.C. Board of Pharmacy 110 Centerview Drive, Suite 201 (29210) P.O. Box 11927 Columbia, SC 29211-1927 Medication Therapy Management (services include but are not limited to): 3HUIRUPLQJ RU REWDLQLQJ QHFHVVDU\ DVVHVVPHQWV RI WKH SDWLHQW¶V KHDOWK VWDWXV )RUPXODWLQJ D PHGLFDWLRQ WUHDWPHQW SODQ 6HOHFWLQJ LQLWLDWLQJ PRGLI\LQJ RU DGPLQLVWHULQJ PHGLFDWLRQ WKHUDS\ 0RQLWRULQJ DQG HYDOXDWLQJ WKH SDWLHQW¶V UHVSRQVH WR WKHUDS\ LQFOXGLQJ VDIHW\ DQG HIIHFWLYHQHVV 3HUIRUPLQJ D FRPSUHKHQVLYH PHGLFDWLRQ UHYLHZ WR LGHQWLI\ UHVROYH DQG SUHYHQW PHGLFDWLRQUHODWHG SUREOHPV LQFOXGLQJ DGYHUVH GUXJ HYHQWV 'RFXPHQWLQJ WKH FDUH GHOLYHUHG DQG FRPPXQLFDWLQJ HVVHQWLDO LQIRUPDWLRQ WR WKH SDWLHQW¶V RWKHU SULPDU\ FDUH SURYLGHUV 3URYLGLQJ YHUEDO HGXFDWLRQ DQG WUDLQLQJ GHVLJQHG WR HQKDQFH SDWLHQW XQGHUVWDQGLQJ DQG DSSURSULDWH XVH RI KLV RU KHU PHGLFDWLRQV 3URYLGLQJ LQIRUPDWLRQ VXSSRUW VHUYLFHV DQG UHVRXUFHV GHVLJQHG WR HQKDQFH SDWLHQW DGKHUHQFH ZLWK KLV RU KHU WKHUDSHXWLF UHJLPHQV &RRUGLQDWLQJ DQG LQWHJUDWLQJ 0HGLFDWLRQ 7KHUDS\ 0DQDJHPHQW VHUYLFHV ZLWKLQ WKH EURDGHU KHDOWKFDUH PDQDJHPHQW VHUYLFHV SURYLGHG WR WKH SDWLHQW Page 2 of 2 American LegalNet, Inc. www.FormsWorkFlow.com