Fillable Printable Form 30410
Fillable Printable Form 30410
Form 30410
INDIANA BOARD OF PHARMACY
PROFESSIONAL LICENSING AGENCY
402 West Washington Street, Room W072
Indianapolis, Indiana 46204
Telephone: (317) 234-2067
E-mail: [email protected]
www.pla.IN.gov
DO NOT WRITE ABOVE THIS LINE
APPLICATION FOR PERMIT TO OPERATE, MAINTAIN, OPEN,
OR ESTABLISH A PHARMACY IN THE STATE OF INDIANA
State Form 30410 (R14 / 6-17)
Approved by State Board of Accounts, 2017
FACILITY INFORMATION
Please check appropriate box below and send proper fee as noted on enclosed instructions.
New store
Name of facility
If change of owner, previous name of facility
Location of pharmacy (number and street, city)
If change of location, old location if different street address (number and street, city)
Change of ownership
Change of location / remodel
Fee exempt (for CSR only) State CSR
County or state ownership Application is enclosed
Name of qualifying pharmacist (must be removed from old store prior to store opening)
County
License number of qualifying pharmacist
ZIP code
Telephone number
PHYSICAL INFORMATION
Rx counter top dimensions
Are there any interior doors leading to space not included above? (If yes, explain.)
Proposed date of opening, relocation, or acquisition (month, day, year)
Room dimensions
Wareroom
Basement 2nd floor
A favorable inspection report by a Board's inspector is required before operations in a
new store or a new location may commence. Inspections are made only after pharmacy
is stocked as permitted by law; give Board ample notice.
( )
INSTRUCTIONS:
1. The fees for this application, payable to the Indiana Professional Licensing Agency, in accordance with 856 IAC 1-27-1 are as follows:
a. The initial application fee for a new store is $100;
b. The application fee for a change of ownership is $50;
c. The application fee for a change of location is $50;
d. The application fee for a remodel is $50.
2. The completed application and fees should be mailed to the address listed in the upper right hand corner of this form.
3. All fees are non-refundable and non-transferable.
4. Please refer to the instructions on our website, www.pla.in.gov, for the licensing requirements.
5. Submit a drawing or blueprint showing the physical size (list linear dimensions) and general layout of the floor plan. In specific, show the location of the
prescription counter top and give the linear dimensions, show the location of the refrigerator, and prescription sink.
6. The completed application should be filed at least thirty (30) days prior to the anticipated date of opening, remodeling, or change of location. Change of
ownership applications shall be filed within ten (10) days of the acquisition. You must secure the federal application from the DEA office. Fill out and mail the
DEA application indicating that your Indiana Controlled Substance Registration is pending. Mail the federal form to the DEA when you mail your application
to this office. The DEA application may take up to twelve (12) weeks to process. It is your responsibility to notify the DEA of the change of location. In case
of change of locations, neither the permit or CSR numbers will change.
Current pharmacy license number
Date of Board approval (month, day, year) CSR number
Case manager
FOR AGENCY USE ONLY
Permit number Date of issuance (month, day, year)
Identification number
Receipt
Date of inspection (month, day, year)
Inspection by
Application fee Date fee paid (month, day, year)
NCPDP number
(If you do not have a number, please provide to the Board of Pharmacy upon receipt.)
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Inspect account
Yes No
If yes, provide inspect account number
Reset Form
PERMIT CLASSIFICATION
Check the appropriate box and fill in appropriate data.
TYPE I. A retail permit for a pharmacy that provides pharmaceutical care to the general public by the dispensing of a drug or device.
TYPE II. An institutional permit for hospitals, clinics, health care facilities, sanitariums, nursing homes, or dispensaries that offer pharmaceutical
care by dispensing a drug product to an inpatient under a drug order or to an outpatient of the institution under a prescription.
TYPE III. (a.) A permit for a pharmacy that is NOT open to the general public; or located in an institution listed under TYPE II permit; AND
provides pharmaceutical care to a patient who is located in an institution or in the patient's home, or;
(b.) A permit for a pharmacy not open to the general public that provides pharmaceutical care by dispensing drugs and devices to
patients exclusively through the United States Postal Service or other parcel delivery services, or;
(c.) A permit for a pharmacy that engages exclusively in the preparation and dispensing of diagnostic or therapeutic radioactive drugs, or;
(d.) A permit for a pharmacy open to the general public that provides pharmaceutical care by engaging in an activity under a TYPE I
permit. A pharmacy that obtains a TYPE III permit may provide services to a home health care patient; a long term care facility; or a
member of the general public.
SCHEDULE OF LICENSED PHARMACISTS IN ATTENDANCE AT PHARMACY
Each pharmacist must personally sign, and legibly print their name, list license number, and hours worked here and elsewhere. Every pharmacy shall
have a manager who shall be a pharmacist licensed under the laws of Indiana. If change of manager during term of permit, change of manager form
must be filed. A pharmacist may qualify only one (1) pharmacy permit.
Signature of manager (qualifying pharmacist)
License number Weekly hours Place / hours worked (if employed elsewhere)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Total weekly hours
A.M. to P.M.
A.M. to P.M.
SCHEDULE OF HOURS OPEN FOR BUSINESS
RULE 6.1. DRUGSTORES, PHARMACIES, APOTHECARY SHOPS
A.M. to P.M.
A.M. to P.M.
A.M. to P.M.
A.M. to P.M.
A.M. to P.M.
856 IAC 1-6.1-1 Pharmacy equipment; lack of access between adjacent pharmacies
Authority: IC 25-26-13-4
Affected: IC 25-26-13-18
Sec. 1 (a) In addition to the requirements of IC 25-26-13-18, the qualifying pharmacist for each pharmacy issued a permit by the board shall
be responsible for all decisions concerning the additional fixtures, facilities, and equipment needed by the pharmacy to operate properly in compliance
with the law regulating pharmacies. In making those decisions, the qualifying pharmacist shall consider minimum health, safety, and security measures
as well as the type and scope of practice, the patient’s needs, and the laws and rules that apply.
(b) If requested by a representative of the Indiana board of pharmacy (board), the qualifying pharmacist shall justify, in writing, all decisions
made under this rule.
(c) The board shall determine whether minimum health, safety, and security measures have been satisfactorily met by an applicant for a
pharmacy permit before the permit is issued or at any time the permit is in effect.
(d) If the board determines that a pharmacy does not meet the requirements of IC 25-26-13-18 and this rule, it will identify and notify the
qualifying pharmacist of the deficiencies. The qualifying pharmacist shall correct or cause to be corrected the deficiencies identified within thirty (30)
days of notification by the board of the noncompliance.
(e) Failure to timely correct the deficiencies identified is grounds for denial or revocation of a permit.
(f) To assure that no pharmacy is left unattended by a pharmacist while that pharmacy is in operation, no means of access may be constructed
or maintained between adjacent pharmacies. (Indiana Board of Pharmacy; 856 IAC 1-6.1-1; filed June 20, 2001, 3:59 p.m.: 24 IR 3651)
Signature(s) of other pharmacist(s)
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OWNERSHIP TYPE
Check the appropriate box below and provide requested information for owners and agents.
A. INDIVIDUAL - If pharmacist,list name followed by Indiana license number and home address.
B. INDIVIDUAL - If non-pharmacist, list name and home address.
C. PARTNERSHIP - List names of all partners, Indiana license number if pharmacist, and home address.
D. CORPORATION - Give name of corporation, followed by names and home addresses of all officers. Indiana license number following if pharmacists.
E. ESTATE - Name of executor and attach certified copy of order of appointment.
F. STATE OWNERSHIP - List names of trustees or appointed official in charge.
G. COUNTY OWNERSHIP - List names of trustees or appointed official in charge.
NAME HOME ADDRESS (number and street, city, state, and ZIP code)
INVENTORY VALUATION
Expressed as percentages of total value in licensed area.
ABSENCE OF PHARMACIST
Legend drugs % Other items % Total %
Does the pharmacy engage in remote practice?
Yes No
A pharmacy holding a TYPE I or TYPE II permit may be open to the general public without a pharmacist on duty, if permission is obtained from the Board.
A register showing the time the pharmacy is opened and closed must be maintained. All merchandise that can only be dispensed by a pharmacist must
be secured when the pharmacist is absent and only the pharmacist may have access to that merchandise. During the pharmacist's absence, a sign at
least twenty (20) by thirty (30) inches shall be prominently displayed in the prescription department stating "Prescription Department Closed, No
Pharmacist on Duty". You will be sent an application for this privilege, if you check "Yes".
INQUIRY OF LAW VIOLATIONS
1. Except for minor violations of traffic laws resulting in fines, and arrests or convictions that have been expunged by a
court, has the applicant, any of the agents or listed pharmacists ever been convicted of, or pled guilty or nolo contendre to:
A. A violation of any federal, state or local laws relating to the use, manufacturing, distributing, or dispensing of controlled
substances or of drug addiction?
B. Any offense, misdemeanor, or felony in any state?
2. Is any action pending on any of the above?
I hereby swear or affirm under the penalties of perjury that the above statements are true, complete and correct.
SALE AGREEMENT
Signature of manager (RPH) in charge of store
Telephone number
( )
Signature of owner or agent
Name of person to contact with questions concerning this application
Requirements: To be completed by owner selling a pharmacy.
If incorporated, or more than one owner, President or executive officer in charge as listed with the Board must complete the sale agreement section.
This is to certify and constitute an agreement of sale of the pharmacy at the location listed on this application.
Signature of seller
PHARMACY REQUIREMENTS
Printed name of seller Date effective (month, day, year)
At the minimum, a pharmacy must:
1. be stationary;
2. have a complete enclosure extending from floor to ceiling level enclosing all the products offered for sale under the pharmacy permit;
3. have entry doors capable of being securely locked to prevent entry during those times when the pharmacy is closed;
4. be well lighted and ventilated with clean and sanitary surroundings;
5. be equipped with a sink with hot and cold running water or some means of heating water, a proper sewage outlet, and refrigeration;
6. have a prescription compounding counter providing a minimum of sixteen (16) square feet of unobstructed area or twenty-four (24) square feet, if
two (2) or more pharmacists are on duty at the same time, and the floor area extending the full length of the prescription compounding counter shall
be clear and unobstructed for a minimum of thirty (30) inches from the counter edge;
7. have such additional fixtures, facilities and equipment as the Board requires to enable it to operate properly as a pharmacy in compliance with federal
and state laws and regulations governing pharmacies;
8. the wholesale value of the drug inventory on the licensed items must be at least 10% of the wholesale value of the items in the licensed area; and
9. other minimum requirements are as specified herein.
E-mail address
COMPOUNDING
1. Does your facility engage or plan to engage in sterile compounding?
2. Does your facility engage or plan to engage in non-sterile compounding?
3. If yes to questions 1 or 2, approximately how many sterile and non-sterile compound prescriptions does your
facility prepare each month? _________________________________________________________________
4. Number of compounded medications prepared for practitioner office use: ______________________________
If your facility engages, or plan to engage, in compounding, please provide evidence of USP 795/797 compliance
(Example: hood inspection reports, policies and procedure regarding sterile and non-sterile compounding, etc.).
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Do you intend to utilize the "Absence of Pharmacist" privilege under IC 25-26-13-19?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If your answer is “Yes” to any of the following, explain fully in a sworn affidavit, including all related details, and provide copies of all relevant arrest or
court documents. Describe the event including the location, date and disposition. Falsification of any of the following is grounds for permanent revocation
of the license or permit issued pursuant to this application.
