Physical Location

Resident

Secondary TypePlease Choose One

Kiosk

Remote Dispensing Site Pharmacy

Remote Hospital Site Pharmacy

Resident Pharmacies:

1. A detailed floor plan showing proposed pharmacy area including size and security (not applicable for kiosk);
2. A copy of the pharmacy lease agreement (if not applicable, a zoning statement)
3. A list of officers or partners, if applicable
4. A list of similar businesses, if applicable
5. Disciplinary orders, if applicable
6. Denial letters, if applicable
7. Application fee (this fee is nonrefundable)

Non-Resident Pharmacies:

1. A copy of the pharmacy’s home state permit
2. A copy of the hospital’s current equivalent license or permit.
3. A list of officers or partners, if applicable
4. A list of similar businesses, if applicable
5. Disciplinary orders, if applicable
6. Denial letters, if applicable
7. Application fee (this fee is nonrefundable)

Permit Number

Business Name

Physical Street Address

Physical Suite#

Physical City

Physical County Select Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Outside of Arizona Pima Pinal Santa Cruz Yavapai Yuma

Physical State Select AA AB AE AK AL AP AR AS AZ CA CO CT DC DE Dr FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR Other PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY

Physical Zip Code

Phone#

Fax

Email Address

Mailing Street Address

Mailing Suite No

Mailing City

Mailing County Select Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Outside of Arizona Pima Pinal Santa Cruz Yavapai Yuma

Mailing State Select AA AB AE AK AL AP AR AS AZ CA CO CT DC DE Dr FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR Other PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY

Mailing Zip Code

Remote Pharmacy or Kiosk ID / Name

FEIN

Physical Street Address

Physical Suite No

Physical City

Zip Code

Physical County Select Apache Cochise Coconino Gila Graham Greenlee La Paz Maricopa Mohave Navajo Outside of Arizona Pima Pinal Santa Cruz Yavapai Yuma

Physical State Select AA AB AE AK AL AP AR AS AZ CA CO CT DC DE Dr FL FM GA GU HI IA ID IL IN KS KY LA MA MB MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR Other PA PR RI SC SD TN TX UT VA VI VT WA WI WV WY

Phone Number

Ext

Fax Number

Email Address

Name of Supervising Pharmacist

Arizona Pharmacist License Number

Expiration Date

I declare under penalty of perjury under the laws of the state of Arizona that the information I have provided in this application is true and correct to the best of my knowledge.

A.R.S. § 41-1030 (B)

An agency shall not base a licensing decision in whole or in part on a licensing requirement or condition that is not specifically authorized by statute, rule or state tribal gaming compact. A general grant of authority in statute does not constitute a basis for imposing a licensing requirement or condition unless a rule is made pursuant to that general grant of authority that specifically authorizes the requirement or condition.

A.R.S. § 41-1030 (D)

This section may be enforced in a private civil action and relief may be awarded against the state. The court may award reasonable attorney fees, damages and all fees associated with the license application to a party that prevails in an action against the state for a violation of this section.

A.R.S. § 41-1030 (E)

A state employee may not intentionally or knowingly violate this section. A violation of this section is cause for disciplinary action or dismissal pursuant to the Agency's adopted personnel policy.

A.R.S. § 41-1030 (F)

This section does not abrogate the immunity provided by section 12-820.01 or 12-820.02.