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)
|
$500.00
|
Duplicate Certificate
(include written request with fee) |
$25.00 |
Duplicate Wallet Card
(include written request with fee) |
$25.00 Pharmacist
$15.00 Technician |
| Emergency Medication Kit (IEMK) |
$100.00/$300.00 |
Extern/Intern (PHARMACY STUDENT)
Controlled Substance Registration |
$50.00 |
| Home Health/Hospice Permit |
$50.00 |
Initial Pharmacist License
(NOT FOR TRANSFER) |
$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
|
$350.00 |
| 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
|