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
|