Applications and Fees

To access any application listed below, please visit the Licensing Gateway.

Amendment Form For License or Registration
(address, name, employment)
Amendment Form For Permit
(business name, address, responsible party (not Pharmacist in charge change)
Compounding Certificate Application
(This application is designed to be a fillable form for your convenience; however, an original signature will be required.)
Controlled Substance Registration Only $50.00
​Drug Facility Permit (In-State and Out of State)​

Duplicate Certificate
(include written request with fee)
Duplicate Wallet Card
(include written request with fee)
$25.00 Pharmacist
$15.00 Technician
Emergency Medication Kit (IEMK)​ $100.00/$300.00
Controlled Substance Registration
Home Health/Hospice Permit​​ $50.00
Initial Pharmacist License
$100.00 License Fee
+ $50.00 Controlled Substance Fee
(if applicable)
and $40.00 Background Check Fee
Medical Equip. Suppliers Permit​ $150.00
Medical Gas Wholesaler​ $50.00
Non-Resident Facility​ $300.00
Outsourcer​ $300.00 + $50.00
(Controlled Substance if applicable)
Pharmacist License Renewal $105.00
Pharmacist in Charge Change​ $300.00
Pharmacy Benefit Manager Application for License (Calendar Year 2020) $500.00
Pharmacy Permit and Pharmacy Controlled Substance Registration $350.00​
​Physician Dispensing Permit 
Preliminary Application for License Transfer $200.00 License fee
+ $40.00 Background Check Fee
+ $50.00 Control Substance Fee
(if applicable)
= $290.00 TOTAL
Pharmacy Services Permit $100.00
Pharmacy Technician Application $50.00 Registration Fee
+ $40.00 Background Check Fee
= $90.00 TOTAL
Unused/Unneeded Medication Donation Permit No Fee
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