Arizona State Board of Pharmacy

Application for Pharmacy Permit

Instructions

Instructions

Physical Location
Secondary Type



Applicable Statutes and Rules

Please familiarize yourself with the statutes and rules listed below.

Statutes
Rules


A.R.S. § 32-1927.02, 1929, 1930, 1931, 1933, 1934

A.R.S. § 32-1961 through 1977

A.A.C R4-23-601, 602, 606 through 621

A.A.C R4-23-652 through 682

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


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

City
Zip Code
County
State

Ownership Information

Name of Owner(s)
Phone
Ext
Fax


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
Pharmacy Square Footage
Number of beds
Name of hospital manager or administrator
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 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.


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 ever been taken against any of the permits held by this business at either a state or federal level? 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 either a state or federal level? If yes, provide full details.
Has the owner, any officer or active partner ever been denied a permit in this state or any other jurisdiction? 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.
Will a medical practitioner receive compensation, either directly or indirectly, from the pharmacy? If yes, indicate the name, state of licensure and license number of the medical practitioner.

Pharmacist In Charge (PIC) Information


Attachments

A detailed floor plan showing proposed pharmacy area including size and security


A copy of the pharmacy lease agreement (if not applicable, a zoning statement)

A list of officers or partners, if applicable

A list of similar businesses, if applicable

Disciplinary orders, if applicable


Denial letters, if applicable
A copy of the pharmacy’s home state permit
A list of officers or partners, if applicable
A list of similar businesses, if applicable
Disciplinary orders, if applicable
Denial letters, if applicable

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.

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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