Application For Non-Resident Pharmacy Permit
Application For Non-Resident Pharmacy Permit Form. This is a Mississippi form and can be use in Board Of Pharmacy Statewide.
Tags: Application For Non-Resident Pharmacy Permit, Mississippi Statewide, Board Of Pharmacy
Street Address: Mailing Address: 204 Key Drive Suite D Madison, MS 39110 P.O. Box 24507 Jackson, MS 39225-4507 Office: 601-605-5388 Fax: 601-605-9546 APPLICATION FOR NON-RESIDENT PHARMACY PERMIT January 1, 2010 - December 31, 2011 FEE - $300.00 Business Name: e-mail address: Street Address: Web Address: Mailing Address Fax: City, State, Zip: Telephone: County: Principle Pharmacy Owner(s) or officers if Corporation: (Attach list if necessary) (Name) (Address) (E-mail) (Name) (Address) (E-mail) Briefly describe all pharmacy services conducted by your facility. Does your facility host one or more internet websites? [ ]YES [ ]NO If yes, list each web address hosted by your facility. If applicable, describe in detail all internet pharmacy services. Attach a copy of your facility's most recent inspection report conducted by the State Board of Pharmacy in your state. Name typed or printed Pharmacist's signature Date: _____________________ OFFICE USE ONLY PHARMACY PERMIT NUMBER:____________ FILE NUMBER:_____________________ DATE ISSUED:___________________________ RECEIPT NUMBER:_________________ American LegalNet, Inc. www.FormsWorkFlow.com SEC. 73-21-106. Registration requirement for nonresident pharmacies that ship, mail, or deliver drugs into state. (1) Any pharmacy located outside this state that ships, mails or delivers, in any manner, controlled substances, prescription or legend drugs or devices into this state shall be considered a nonresident pharmacy, shall be registered with the board, and shall disclose to the board all of the following: (a) The location, names, and titles of all principal corporate officers and all pharmacists-in-charge. A report containing this information shall be made on a biennial basis and within thirty (30) days after any change of office, corporate officer or pharmacist-in-charge; (b) That it complies 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 pursuant to 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 registering with 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; and (c) That it maintains its records of controlled substances, or 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. (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 registration fee for nonresident pharmacies shall be the same as the fee as set by subsection (4) of Section 73-21-105. (4) The registration requirements of this section shall apply only to a nonresident pharmacy that only ships, mails or delivers controlled substances, prescription or legend drugs and devices into this state pursuant to a prescription (5) The board may deny, revoke or suspend a nonresident pharmacy registration only for: (a) Failure to comply with any requirement of this section; or (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. (6) It is unlawful for any nonresident pharmacy that is not registered pursuant to this section to advertise its services in this state, or for American LegalNet, Inc. www.FormsWorkFlow.com any person who is a resident of this state to advertise the pharmacy services of a nonresident pharmacy that has not registered 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, 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. SOURCES: Laws, 1994, ch. 5 13, Sec. 9, eff from and after July 1, 1994 American LegalNet, Inc. www.FormsWorkFlow.com