Arizona State Board of Pharmacy

Application for Medical Gas or DME Distributor Permit

Instructions

Instructions

Before beginning this application, please review the application instructions on the Board's website. If you have any questions, please contact the Board office at (602) 771-2727 or email [email protected]

Please Choose One
Physical Location

Secondary Type


Applicable Statutes and Rules

Please familiarize yourself with the statutes and rules listed below. The statutes and rules are available for review on the Board’s website, https://pharmacy.az.gov/.

Statutes

A.R.S. § 32-1927.02, 1929, 1930, 1931, 1933, 1939

Rules

A.A.C R4-23-601, 602

A.A.C R4-23-692 (CMG Distributor),R4-23-693 (CMG/DME Supplier)

Click here to review the statutes and rules

Business Information


Business Name

FEIN

Physical Street Address

Physical Suite # (Please use appropriate prefix (Example: Suite 101, Apt. 101, #101, etc.))
Physical Zip Code
Physical City
Physical State
Physical County
Phone
Ext
Fax
Email [email protected]

Street Address
Suite # (Please use appropriate prefix (Example: Suite 101, Apt. 101, #101, etc.))

Zip Code
City
State
County

Ownership Information

Name of owner(s)
Phone
Ext
Fax
Is this entity a corporation or partnership with officers or partners? If yes, provide the name, title and address of each officer or partner. You may enter this information here or attach a list later in the application process.

If yes, indicate the former owner's name, AZ permit number, and permit name.


Other Business Information

Indicate the date your business opened or will open
Has this entity ever operated under any other trade or business names? If yes, indicate the trade or business names used.
Has this entity ever operated a similar business (e.g. DME, pharmacy, manufacturer, wholesaler, 3PL) in any other state or jurisdiction? If yes, provide the name and location of each similar business. You may enter this information here or attach a list later in the application process.

Does the entity transfill compressed medical gas?

Regulatory Questions

Has the owner, any officer or active partner, ever been convicted of an offense involving moral turpitude, a felony offense, or any drug-related offense or have any currently pending felony or drug-related charges? If yes, provide full details, which must include the charge, conviction date, jurisdiction and location.
Has any formal disciplinary action been taken against any of the permits held by this business at this location at either a state or federal level within the last five (5) years? If yes, provide full details, which must include the nature and date of each action and the state or jurisdiction involved. You must also provide copies of the orders relating to each disciplinary action.
Are there any disciplinary actions or sanctions pending against any of the permits held by this business at this location at either a state or federal level? If yes, provide full details.
Has the owner, any officer or active partner been denied a permit for this location in this state or any other jurisdiction within the last five (5) years? If yes, provide full details, which must include the state or jurisdiction and the date of the denial. You must also provide a copy of the order or letter of denial.
Has this business manufactured, processed, transfilled, packaged, or labeled a compressed medical gas in Arizona, or manufactured, processed, transfilled, packaged, or labeled a compressed medical gas outside Arizona and shipped into Arizona within the last four (4) years? If yes, provide a list of products shipped within the last four (4) years.
Has this business distributed durable medical equipment in Arizona to a person other than a patient or consumer, or distributed out of or within the State of Arizona within the last four (4) years?

Designated Representative Information

Name of Manager Or Responsible Person
Email Address
Emergency Phone Number
Ext

Attachments

Review Your Information

Affirm And Submit

Please be advised of the following pursuant to Arizona Revised Statutes (A.R.S.) § 41-1030:


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.

Pursuant to section 41-1093.01, Arizona Revised Statutes, an agency shall limit all occupational regulations to regulations that are demonstrated to be necessary to specifically fulfill a public health, safety or welfare concern. Pursuant to sections 41-1093.02 and 41-1093.03, Arizona Revised Statutes, you have the right to petition this agency to repeal or modify the occupational regulation or bring an action in a court of general jurisdiction to challenge the occupational regulation and to ensure compliance with section 41-1093.01, Arizona Revised Statutes.

Please note that after you click the Submit button, you cannot make changes to your application.

Mailing Address: P.O. Box 18520, Phoenix, AZ 85005 Phone: (602) 771-2727

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