Application For Non-Resident Pharmacy Permit | Pdf Fpdf Doc Docx | Mississippi

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Application For Non-Resident Pharmacy Permit | Pdf Fpdf Doc Docx | Mississippi

Application For Non-Resident Pharmacy Permit

This is a Mississippi form that can be used for Board Of Pharmacy within Statewide.

Alternate TextLast updated: 8/22/2016

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Street Address: 6360 I-55 North Suite 400 Jackson, MS 39211 Office: 601-899-8880 Fax: 601-899-8851 APPLICATION FOR NON-RESIDENT PHARMACY PERMIT January 1, 2016 - December 31, 2017 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) (Name) (Name) (Address) (Address) (E-mail) (E-mail) Briefly describe all pharmacy services conducted by your facility. 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'smost recent inspection report conducted by the State Board of Pharmacy in your state. Pharmacist's signature Name typed or printed Mississippi License Number OFFICE USE ONLY PHARMACY PERMIT NUMBER: DATE ISSUED: FILE NUMBER: RECEIPT NUMBER: American LegalNet, Inc. www.FormsWorkFlow.com Miss. Code Ann. § 73-21-106 MISSISSIPPI CODE of 1972 *** Current through the 2012 Regular Session *** TITLE 73. PROFESSIONS AND VOCATIONS CHAPTER 21. PHARMACISTS MISSISSIPPI PHARMACY PRACTICE ACT Miss. Code Ann. § 73-21-106 (2013) § 73-21-106. Registration requirement for nonresident pharmacies that ship, mail, or deliver drugs into state [Repealed effective July 1, 2016] (1) Any pharmacy located outside this state that ships, mails or delivers, in any manner, controlled substances or prescription or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 permitted by 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 under 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 being permitted by 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; (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; and (d) Certify that it understands Mississippi pharmacy laws and regulations and agrees to comply with those laws and regulations and any other state or federal laws that apply to the practice of pharmacy. The pharmacist-in-charge must hold a Mississippi pharmacist license, be licensed to practice pharmacy in the state of residence of the nonresident pharmacy, and be current and in good standing with the licensing boards of both states. (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 permit fee for nonresident pharmacies shall be the same as the fee as set by subsection (4) of Section 73-21-105. American LegalNet, Inc. www.FormsWorkFlow.com (4) The permit 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 permit only for: (a) Failure to comply with any requirement of this section or Section 41-29-125; (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 permitted 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 is not permitted 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; Laws, 2011, ch. 466, § 3; Laws, 2011, ch. 546, § 33, eff from and after passage (approved Apr. 26, 2011.) American LegalNet, Inc. www.FormsWorkFlow.com

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