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Application For Louisiana Pharmacy Permit Located Out-Of-State Form. This is a Louisiana form and can be use in Board Of Pharmacy Statewide.
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Tags: Application For Louisiana Pharmacy Permit Located Out-Of-State, Louisiana Statewide, Board Of Pharmacy
Louisiana Board of Pharmacy
3388 Brentwood Drive
Baton Rouge, Louisiana 70809-1700
www.pharmacy.la.gov
Application for Louisiana Pharmacy Permit Located Out-of-State
Notices
•
Chapter 11 of the Board’s rules enumerates the minimum requirements for pharmacies and
prescription departments, and Chapter 23 identifies the additional requirements for non-resident
or out-of-state pharmacies. All of our laws and rules may be accessed on our website, at
www.pharmacy.la.gov.
•
The Louisiana Board of Pharmacy requires compliance with current federal standards applicable
to sterile compounding activities (USP Chapter 797). Pharmacies electing to engage in such
activities for the benefit of Louisiana residents shall demonstrate their compliance with current
federal standards by the attachment of appropriate documentation to their application.
•
We encourage you to type your entries on the application. If you choose to print, please do so
legibly using blue or black ink. Do not use pencil. Applications completed in pencil, or those with
illegible entries, shall be returned to the applicant’s designated contact person.
•
Please do not re-format the application to accommodate your entries. Applications reformatted
from the posted version shall be returned to the applicant’s designated contact person.
•
Please do not use entries such as “See attached”; an appropriate entry shall be made in each
section. Incomplete applications shall be returned to the applicant’s designated contact person.
•
Blank applications may be copied as needed; please use standard copy paper. Applications
completed or reproduced on thermal or waxy paper will not be accepted, and they shall be
returned to the applicant’s designated contact person.
•
We encourage you to review your application and attachments prior to submission to the Board.
Our experience shows the most common reason to return an application is for incomplete
documents. This will only delay the processing of your application.
•
The application shall be submitted to the Board office, at the address noted hereinabove, at least
thirty (30) days prior to the anticipated opening date of the new pharmacy or the ownership
transfer.
•
Your application and fee will be valid for up to one year after the date of its receipt at the Board
office. If the permit has not been issued by that date, the application shall be voided and the fee
shall be forfeited.
•
Pharmacy permits expire at midnight on December 31 of every calendar year, regardless of the
date of issuance. Pharmacies may not operate with expired permits.
Form No. 52
Page 1 of 6
Rev 07-01-2011
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Louisiana Board of Pharmacy
3388 Brentwood Drive
Baton Rouge, Louisiana 70808-2537
Telephone 225.922.0852 ~ Facsimile 225.925.6499
Website: www.pharmacy.la.gov ~ Email: info@pharmacy.la.gov
Application for Louisiana Pharmacy Permit Located Out-of-State
(Complete this application for pharmacies located outside of Louisiana.)
Please type all entries; if printing, please do so legibly using blue or black ink. All checks or money orders for the
$175.00 fee shall be made payable to “Louisiana Board of Pharmacy.” Mail this application, all attachments, and fee
to the address noted at the top of this page. Incomplete applications will be returned to the contact person.
Section 1 – Reason for Application [select one] & Date of Opening
_____ New Pharmacy Permit
_____ Ownership Transfer
Anticipated Date of Opening _______________________
Section 2 – Pharmacy Information
Name (d/b/a) _____________________________________________________________________________________________
Physical Address __________________________________________________________________________________________
City, Parish, State, ZIP _____________________________________________________________________________________
Telephone ___________________________ Facsimile ___________________________ Email __________________________
Toll-free Telephone ____________________________
Resident State Pharmacy Permit No. _________________ Expiration Date ____________________
DEA Registration No. _________________________ Expiration Date ______________________
Mailing Address __________________________________________________________________________________________
City, Parish, State, ZIP _____________________________________________________________________________________
Has this pharmacy ever been the subject of any disciplinary or other adverse action by any other licensing agency, or by any
other government agency, or by any local, state, or federal law enforcement agency, or by any local, state, or federal court?
_____ Yes
_____ No
If you answered “Yes” to this question, please attach a letter of explanation as well as a certified copy of the final disposition for each
incident. If charges were dismissed, please provide a letter from the appropriate authority confirming dismissal of the charges. Your
failure to disclose any prior disciplinary or adverse action or criminal history may result in the denial of this application or disciplinary
action against the permit.
Section 3 – Applicant’s Designated Contact Person [for processing of application]
Name _________________________________________________________________________________________________
Company ______________________________________________________________________________________________
Address _______________________________________________________________________________________________
City, State, ZIP __________________________________________________________________________________________
Telephone _______________________ Facsimile ___________________ Email _____________________________________
For Board Use Only:
Date application received: ____________________ Check / M.O. # __________________________ Amt. _________________
Interview Required: Yes / No
Form No. 52
Compliance Officer: ___________
Page 2 of 6
Permit No. ____________
Issued: ___________
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Section 4 – Pharmacy Ownership [select one]
Please identify the legal entity which owns the pharmacy identified in Section 2.
_____ Individual
Name: ________________________________________________________________________
_____ Partnership
Name: ________________________________________________________________________
_____ Corporation
Name: ________________________________________________________________________
_____ LLC
Name: ________________________________________________________________________
_____ Association
Name: ________________________________________________________________________
_____ Government
Name: ________________________________________________________________________
_____ Other [explain]
Name: ________________________________________________________________________
Federal Employment Identification Number (FEIN) of this legal entity: _______________________________________________
Section 5 – Owner’s Address
Please enter the business address of the entity identified in Section 4.
Physical Address __________________________________________________________________________________________
City, State, ZIP ___________________________________________________________________________________________
Telephone ________________ Facsimile ________________ Email ___________________ Website ______________________
Mailing Address ___________________________________________________________________________________________
City, State, ZIP ____________________________________________________________________________________________
Section 6 – Ownership of Other Pharmacies
Does the entity identified in Section 4 currently own any other pharmacy?
_____ Yes
_____ No
If the entity identified in Section 4 does own any other pharmacy in any state, please attach an itemized listing of all such pharmacies.
For each such entry, please provide the name and physical address of the pharmacy, the permit number of that pharmacy, and
whether or not that pharmacy has ever been sanctioned or disciplined by any state board of pharmacy or by any local, state, or
federal government agency or by any local, state, or federal court.
Section 7 – Owner’s Managing Officer
The person identified in this section shall be the individual authorized by the owner(s) to act on their behalf and shall be responsible
to the Board for the proper operation of the pharmacy in compliance with all laws and regulations.
Name __________________________________________________________________________________________________
Position/Title _____________________________________________________________________________________________
Mailing Address __________________________________________________________________________________________
City, State, ZIP ___________________________________________________________________________________________
Telephone _______________________ Facsimile _______________________ Email __________________________________
Have you ever been arrested, indicted, or charged with any crimes in any state?
_____ No
_____ Yes
Have you ever been the subject of any disciplinary action by any government agency,
or have you ever been the subject of any legal or other adverse action from any law
enforcement agency or any local, state, or federal court?
_____ No
_____ Yes
Are you currently charged with the commission of a felony in any state?
_____ No
_____ Yes
Have you ever been convicted of a felony in any state?
_____ No
_____ Yes
If you answered “Yes” to any of the four questions above, please attach a letter of explanation as well as a certified copy of the final
disposition for each incident. If charges were dismissed, please provide a letter from the appropriate authority confirming dismissal
of the charges. Your failure to disclose any prior disciplinary or criminal history may result in the denial of this application or
disciplinary action against the permit.
Form No. 52
Page 3 of 6
Rev 07-01-2011
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Section 8 – Registered Agent for Service of Process
In the absence of a designated agent, the applicant will be deemed to have designated the Louisiana Secretary of State to be its
agent, upon whom may be served all legal process in any action or proceeding against the pharmacy.
Name ________________________________________________________________________________________________
Mailing Address ________________________________________________________________________________________
City, State, ZIP _________________________________________________________________________________________
Section 9 – Ownership Transfer of an Existing Pharmacy
If this option was selected in Section 1, please identify the existing pharmacy as it appears on that pharmacy’s permit.
Pharmacy Name (d/b/a) ___________________________________________________________________________________
Physical Address ________________________________________________________________________________________
City, State, ZIP __________________________________________________________________________________________
Existing Louisiana Pharmacy Permit No. __________________ DEA Registration No. __________________
Section 10 – Pharmacist-in-Charge
No person may serve as the pharmacist-in-charge (PIC) of a Louisiana pharmacy permit until the Board has received his properly
executed Affidavit of Acknowledgement and Acceptance of Responsibility of Pharmacist-in-Charge.
Name ________________________________________________________________________________________________
Mailing Address ________________________________________________________________________________________
City, State, ZIP _________________________________________________________________________________________
Telephone ________________________ Facsimile ______________________ Email _________________________________
Resident State Pharmacist License No. _________________________
Louisiana Pharmacist License No. __________________________________________________________________________
Do you serve as the PIC of any other Louisiana pharmacy permit?
_____ No
_____ Yes [Permit No. _________]
Have you ever been arrested, indicted, or charged with any crimes in any state?
_____ No
_____ Yes
Have you ever been the subject of any disciplinary action by any government agency,
or have you ever been the subject of any legal or other adverse action from any law
enforcement agency or any local, state, or federal court?
_____ No
_____ Yes
Are you currently charged with the commission of a felony in any state?
_____ No
_____ Yes
Have you ever been convicted of a felony in any state?
_____ No
_____ Yes
If you answered “Yes” to any of the four questions above, please attach a letter of explanation as well as a certified copy of the final
disposition for each incident. If charges were dismissed, please provide a letter from the appropriate authority confirming dismissal
of the charges. Your failure to disclose any prior disciplinary or criminal history may result in the denial of this application or
disciplinary action against the permit.
Section 11 – Special Services for Louisiana Residents
Will this pharmacy perform any non-sterile compounding services?
_____ No
_____ Yes
Will this pharmacy perform any sterile compounding services?
_____ No
_____ Yes**
Will this pharmacy utilize an Automated Medication System (AMS)?
_____ No
_____ Yes
Will this pharmacy dispense or distribute any prescription medical devices?
_____ No
_____ Yes
Will this pharmacy dispense or distribute any medical gases?
_____ No
_____ Yes
Will this pharmacy utilize a website to facilitate its dispensing operations?
_____ No
_____ Yes
If so, is the site certified by VIPPS?
_____ No
_____ Yes
Location of server: _______________________________
** Please attach evidence of compliance with current federal standards for sterile compounding activities (USP Chapter 797).**
Form No. 52
Page 4 of 6
Rev 07-01-2011
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Section 12 – Required Attachments
•
All Pharmacies
Identify all individuals holding an ownership interest, as well as their percentage
or fraction thereof, in the entity identified in Section 4. For each person so identified, please
provide their full name, date of birth, Social Security number, addresses (business and
home), and telephone numbers (business and home). Further, if any of these individuals
hold a professional license or credential from any state government agency, please indicate
their designation and provide a copy of the license or credential. Finally, please indicate
whether that license or credential has ever been sanctioned or disciplined, and if so, provide
a copy of that agency decision.
Identify all officers, partners, and board members, along with their position titles.
For each person so identified, please provide their full name, date of birth, Social Security
number, addresses (business and home), and telephone numbers (business and home).
Further, if any of these individuals hold a professional license or credential from any state
government agency, please indicate their designation and provide a copy of the license or
credential. Finally, please indicate whether that license or credential has ever been
sanctioned or disciplined, and if so, provide a copy of that agency decision.
With respect to the applicant’s pharmacy permit from the resident state board of
pharmacy, please attach a copy of that credential, a copy of the most recent inspection
report, and a letter from the resident state board of pharmacy attesting to the current status
of the resident state permit, with information as to whether or not that permit has ever been
sanctioned or disciplined by that agency, and if so, a copy of that agency decision.
With respect to the compounding of sterile preparations for Louisiana residents,
attach evidence of compliance with current federal standards (USP Chapter 797).
•
Ownership Transfers
By the attached letter, the owner of the existing pharmacy shall confirm the pending sale to
the applicant, as well as the anticipated transfer date.
Section 13 – Attestations
By their signatures below, the owner’s managing officer and the pharmacist-in-charge attest to their knowledge and agreement with
the following statements:
We understand and agree that our application and fee will be valid for up to one year following the date of
receipt in the Board’s office.
We understand and agree that no person shall open, establish, operate, or maintain a pharmacy or
dispense prescriptions to Louisiana residents unless the pharmacy is issued a permit by the Board.
We understand and agree that no permit to operate a pharmacy shall be granted or renewed unless
evidence satisfactory to the Board ensures that a pharmacist will be on duty during normal business
hours.
We understand and agree that the parties executing this application may be required to personally appear
before the Board prior to any decision on the permit application.
We understand and agree that no person shall carry on, conduct, or transact business under a name
which contains a part thereof the words “pharmacist”, “pharmacy”, “apothecary”, “apothecary shop”,
“chemist’s shop”, “drug store”, “druggist”, “drugs”, or any word or words of similar or like import, or in any
manner by advertisement, circular, poster, sign, or otherwise describe or refer to a place of business by
the terms of “pharmacy”, “apothecary”, “apothecary shop”, “chemist’s shop”, “drug store”, “drugs”, or any
word or words of similar or like import, unless the place of business is validly permitted by the Board.
We understand and agree a prescription issued solely on the results of answers to an electronic
questionnaire, in the absence of a documented patient evaluation including a physical examination by the
prescriber, is issued outside the context of a valid physician-patient relationship, and is not a valid
prescription, and further, that a pharmacist who dispenses prescription drugs in violation of Section 2515
of the Board’s rules is not acting in the best interest of the patient and is dispensing outside the course of
the professional practice of pharmacy.
We understand and agree that a permit to operate a pharmacy shall not be transferable to a new owner.
We understand and agree that this pharmacy shall be operated in compliance with the Louisiana
Pharmacy Practice Act (La. R.S. 37:1161 to 1250) and the professional and occupational standards found
in Part LIII of Title 46 of the Louisiana Administrative Code, as well as all other federal and state laws and
rules that may be applicable to the scope of services rendered to Louisiana residents at this pharmacy.
Form No. 52
Page 5 of 6
Rev 07-01-2011
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Owner’s Managing Officer
I hereby certify that all of the foregoing and attached information is true and correct to the best of my
knowledge, and further, that I have read, do understand, and do agree with the provisions referenced
above in this section, and further, that this pharmacy will be operated in full compliance with all federal and
state laws and regulations pertaining to the practice of pharmacy.
_____________________________
________________________
Signature of Owner’s Managing Officer
Date
I hereby certify that the Attestations of the Owner’s Managing Officer were signed, subscribed, and sworn
to before me on this ________ day of _________________ in the year __________.
____________________________
Signature of Notary Public
Seal
Required
____________________________
Parish or County
____________________________
Expiration Date of Commission
Pharmacist-in-Charge
I hereby certify that all of the foregoing and attached information is true and correct to the best of my
knowledge, and further, that I have read, do understand, and do agree with the provisions referenced
above in this section, and further, that this pharmacy will be operated in full compliance with all federal and
state laws and regulations pertaining to the practice of pharmacy.
_____________________________
________________________
Signature of Pharmacist-in-Charge
Date
I hereby certify that the Attestations of the Pharmacist-in-Charge were signed, subscribed, and sworn to
before me on this ________ day of _________________ in the year __________.
____________________________
Signature of Notary Public
Seal
Required
____________________________
Parish or County
____________________________
Expiration Date of Commission
Form No. 52
Page 6 of 6
Rev 07-01-2011
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