"Application for Pharmacy - Nonresident License and Controlled Substances Registration" - Rhode Island

This "Application for Pharmacy - Nonresident License and Controlled Substances Registration" is a document issued by the Rhode Island Department of Health specifically for Rhode Island residents with its latest version released on November 18, 2016.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Rhode Island Department of Health.

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Download "Application for Pharmacy - Nonresident License and Controlled Substances Registration" - Rhode Island

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*** Submit This Page With Application ***
***FOR OFFICE USE ONLY***
Receipt #:
ID#:
Issue Date:
License #
PHN
CPHN
Rhode Island
Board of Pharmacy
Room 103
3 Capitol Hill
Providence, RI 02908-5097
Instructions and Application For
Pharmacy - Nonresident
License and
Controlled Substances Registration
New Application
Change of Location (License # __________ )
Controlled Substances Registration
Change in Ownership (License # _________ )
CHOOSE
Practice Specialty:
Central Fill Pharmacy
ONLY
ONE
Long Term Care Pharmacy
Nuclear Pharmacy
Telepharmacy
Compounding
Parenteral
Applicant - Print Pharmacy/Facility Name
Phone: (401) 222-2837
TTY/TDD: (800) 745-5555
Fax: (401) 222-2158
Revised 11/18/2016 jcp
*** Submit This Page With Application ***
***FOR OFFICE USE ONLY***
Receipt #:
ID#:
Issue Date:
License #
PHN
CPHN
Rhode Island
Board of Pharmacy
Room 103
3 Capitol Hill
Providence, RI 02908-5097
Instructions and Application For
Pharmacy - Nonresident
License and
Controlled Substances Registration
New Application
Change of Location (License # __________ )
Controlled Substances Registration
Change in Ownership (License # _________ )
CHOOSE
Practice Specialty:
Central Fill Pharmacy
ONLY
ONE
Long Term Care Pharmacy
Nuclear Pharmacy
Telepharmacy
Compounding
Parenteral
Applicant - Print Pharmacy/Facility Name
Phone: (401) 222-2837
TTY/TDD: (800) 745-5555
Fax: (401) 222-2158
Revised 11/18/2016 jcp
***Detach Page - Do Not Submit With Application ***
GENERAL INFORMATION
Enclosures
The following materials and information should be enclosed within this application packet:
Application Process Overview........................................................................................................... 3
Instructions for Completing Application..............................................................................................5
Application Materials
Application.............................................................................................................................. 6-9
Application Checklist.............................................................................................................. 10
Licensure Requirements
Application Fee of $340.00 (add $100.00 for Controlled Substances Registration for a total of $440.00)
Check or money order only (NOTE: All application fees are non-refundable).
Valid, unexpired license, permit or registration issued by the state in which located.
Compliance with the regulations of this state when dispensing legend drug/devices to residents of this
state.
Resident Agent
A nonresident pharmacy shall designate a resident agent in this state for service of process. If not so
designated, it shall be deemed an appointment by such nonresident pharmacy of the Secretary of State to be
its true and lawful attorney upon whom may be served all legal process in any action or proceeding against
such pharmacy growing out of or arising from such delivery. A copy of any such service of process shall be
mailed to the nonresident pharmacy by the complaining party by certified mail, return receipt requested,
postage prepaid, at the address of such nonresident pharmacy as deignated on the pharmacy’s application for
licensure in this state. If any such pharmacy is not licensed in this state, service on the Secretary of State in
this state only shall be sufficient service.
Upon receipt of a complaint against the nonresident pharmacy, the Rhode Island Board of Pharmacy (BOARD)
shall forward the complaint to the state/provincial boards where the nonresident pharmacy is licensed.
Rules and Regulations
To obtain the Rules and Regulations for your profession visit the A-Z list on the Topics & Programs page at the
following web site. From the list click on the letter for your profession.
http://www.health.ri.gov/atoz/
Rhode Island Board of Pharmacy - Page 2
***Detach Page - Do Not Submit With Application ***
APPLICATION PROCESS OVERVIEW
The licensure process in the State of Rhode Island is conducted by the Rhode Island Department of Health
(HEALTH), Office of Health Professionals Regulation, and the BOARD.
Application Process
This application is to be used for licensing a pharmacy located outside the State of Rhode Island that ships,
mails or delivers prescription drugs and/or devices to a patient in this state, or to apply for a new license due to
a change in ownership or location. Prescription drugs or devices cannot be shipped, mailed, or delivered to a
patient in this state without being licensed by the BOARD. The nonresident pharmacy must maintain, at all
times, a valid unexpired license, permit or registration to operate the pharmacy in compliance with the laws of
the state in which it is located.
A pharmacy license will be issued to a person, owner, corporation, or other legal entity, hereinafter called the
“Licensee”. The license shall entitle the owner to operate such pharmacy at the location specified on the
license and shall not be transferred. When there is a change in ownership, operation and/or location, the
license immediately becomes void and shall be mailed by the licensee to the BOARD. It is the duty of the
owner to immediately notify the BOARD of any proposed change of location or ownership, and to file the
required application prior to the change. Renovating or remodeling an existing pharmacy is not considered a
change of location.
“Change of ownership” means:
a.
In the case of a pharmacy, manufacturer or wholesaler which is a partnership which results in a new
partner acquiring a controlling interest in the partnership;
b.
In the case of a pharmacy, manufacturer or wholesaler which is a sole proprietorship, the transfer of
the title and property to another person;
c.
In the case of a pharmacy, manufacturer or wholesaler which is a corporation:
i.
A sale, lease exchange, or other disposition of all, or substantially all of the property and assets of the
corporation; or
ii. A merger of the corporation into another corporation; or
iii. The consolidation of two or more corporations, resulting in the creation of a new corporation; or
iv. In the case of a pharmacy, manufacturer or wholesaler which is a business corporation, any transfer of
corporate stock which results in a new person acquiring a controlling interest in the corporation; or
v. In the case of a pharmacy, manufacturer or wholesaler which is a nonbusiness corporation, any change
in membership which results in a new person acquiring a controlling vote in the corporation.
All items listed on the “checklist” (page 10) must be submitted for an application to be considered complete. All
applications are considered valid for six months from the day they are received at HEALTH. If you do not
complete the application process and obtain a license within those six months, a new application and fee must
be submitted.
Please allow a minimum of four weeks for the entire licensure process to be completed. If the applicant has
had criminal or disciplinary history in Rhode Island or another state, it may take an additional two or three
months for all pertinent documentation to be received, and a decision to be made regarding the issuance of a
license. This is an estimate of the amount of time that is required to become licensed. The entire process may
take more or less time than estimated.
Rhode Island Board of Pharmacy - Page 3
***Detach Page - Do Not Submit With Application ***
APPLICATION PROCESS OVERVIEW
(continued)
Licenses will be issued within five working days following the Board’s approval of the completed application.
Wall permits are mailed approximately two weeks from the date of issuance, and are mailed to the address
furnished in the application. It is the applicant’s responsibility to notify the BOARD, in writing, if there are
changes during the interim, or at any time after the license is issued. It is the responsibility of the licensee to
notify the BOARD in writing when there is a change in the pharmacist-in-charge.
A nonresident pharmacy must comply with the regulations of this state when dispensing legend drugs or
devices to residents of this state.
HEALTH will not, for any reason, accelerate processing of one applicant at the expense of other applicants.
Once completed, the application will be reviewed, and the applicant will be contacted by the BOARD if further
information is required. Be advised, the applicant may be required to appear for an interview.
NOTE:
Licensure application materials are public records as mandated by Rhode Island law and may be made
available to the public, unless otherwise prohibited by State or Federal Law.
The license will expire on September 30th (regardless of the date issued), and a form will be mailed to renew
the pharmacy license for the period October1st through September 30th. It is the licensee’s responsibility to
maintain an active license. If a renewal is not received, the licensee is to contact the BOARD to followup on the
status of the renewal:
https://healthri.mylicense.com/Verification/
Please continue to review the remaining portions of this application packet for instructions and other materials
necessary to complete the Board application. If you have any questions about this application process, or
would like to check on the status of your BOARD application, please contact the BOARD at (401) 222-2837.
Rhode Island Board of Pharmacy - Page 4
***Detach Page - Do Not Submit With Application ***
INSTRUCTIONS FOR COMPLETING THE BOARD APPLICATION
Read the following instructions and those throughout the application packet carefully before completing the
Board application. Only complete applications with the appropriate fee will be accepted. Failure to
submit all required information and appropriate documentation may result in processing delays. All of the
information provided is subject to change.
General Instructions
1. Make a copy of the application and forms before you begin in case you make a mistake.
2. Type the information or print in blue or black ball-point pen. Board staff will not make assumptions about
illegible information. Be sure to print the licensee’s name in the box provided on the cover page.
3. Provide a response to each section or question; otherwise mark “N/A” for Not Applicable.
4. It is suggested that a copy of the completed application be made before submitting it to the Board.
5. It is the applicant’s responsibility to check on the status of the application.
Completing your Board Application
1. Complete the Board Application pages (6-9). Respond to all components of the application as instructed.
If you attach separate pages in continuation of the Board application, such pages MUST clearly indicate
the section for which such information is being reported.
2. Make a check or money order (in U.S. Funds only) for the application fee of $340.00 (or $440.00 with CSR
application) payable to General Treasurer, State of Rhode Island and staple it to the upper left-hand
corner of the cover page of the application.
3. Attach a copy of the license issued by the state in which located.
Complete all application materials as instructed and arrange them in order as they appear in the application
checklist (see page 10). Do not submit applications without all applicable information, documentation and fee.
Mail these components of the application to:
Rhode Island Department of Health
Board of Pharmacy, Room 103
3 Capitol Hill
Providence, RI 02908-5097
Rhode Island Board of Pharmacy - Page 5
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