ALBOP Files/2020/NRPharmacyApp...Created Date 7/8/2019 10:12:23 AM
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For Ottceじ "Onls' P ヽま 0 Name Alabama State Bonl・ d ofPhallmac lll Village Steet Bininghalュ A■35242 (205)981‐ 2280 2019/2020 NOヽ RESDEヽ T PHARML(:Y 想 PLICA■ ON FOR NEW PERMIr (Vald tbro■ _gh 12 31120) Pel・ nlit Fee S750 Colltl・ o■ od Substallces Fee S300.00 Ifyorr do rtot dispcr$e coltrolled substances. urust colrplete Controlled Subsutccs \\:aiver fonu Go to u+r'w.albop.cotu FEN" Sequndlnthe et・ ent oF晴 "嶽 電 tO NIPD3) For ttce VI● Cた '、 P● ぼ "t■ ｀苺 :0だ eF I Date Palust: Address Cit、 Toll free phone # Fax * Cell■ Supen'isiug Phan[acist_Alabanra Liceuse =_Errrail Elfectlre 6/9/1,{ - Alabaura licrnsed SP is lequired. See rule 690-\-2-.07 (fl }Iail Ordel Prercrlptious. Name of owner: (if cupc'ero. *xh ti:r of o6ccn Alabanu Agent ofRecord: {narne} (Address)________― ― ― ― ― ― ― ― ― ― ― 一 一 一 ― 一 一 ― ― ― ― ― ― ― 一 一 一 一 ― 一 ― ● h° nel ha"nf■ ぬd腱 摯 薇ぬ∞ 雨th the助 鳴 … Admttll“ 翅 “ ●つ LT― m Date Apphed for to●銀 EB m} ructio s dff1plm1'aaio bm ula regrding ro1' licgu, p€toit c n8lstrreo isscd to $e ryPhed tr aI 06.11 6 pstns of tb ryplicrt irr-otrug the opmtio c mrathip of a @amy. m&ctu( stok d*, tr dinnbnql r〕 摯,3"statK3D 3-& 村 … … 議曖 d睡 も藤 desIP● carenged錮 薇 shtt be― 鑢appOmnd● ftt S‐ 餞町●FSute cFtt Sat of施 ぬ四 to be ts… Pharnacy hours for dispetsing dntgs to Alabanu patieots: Monday - Frida]'_Sat St濾 Noruul nrR around time frorn receipt of prescriptious to shipping drugs to AL patieuts (da)s)_ Procedurc to iollow by AL patieats if nrcdicadon is not arailable or if delivery r'ill be dclayed bcyond a nonnrl delivery time Procedure to follow for prcscriptions for an acute illncss. to include delitcry at earliest possible linr (i.e. corrier delivery) or altemative to assur. patient the opportunity to obtair mdication at the earliest possible ti$e Procedurc to follow whcn medicarion is not received aod patient is out ofmcdication aad reguires interim dosage uutil mailed prescription drugs become available Does rhis facilirypreparE sterilc courpoulds? {checf, all thar rpptyr I f=S[ xo I Non-sterlk t:SP <?95> D Sterlle trSP<?9?> Cortrpkt0 compoundlng qu?stlortrilrcs do!,yllordtd ftom our wrbrllc. SoTE: ruoBtltstlnl omrclru's'rllrbt predrct! & 6l oEpourdlq. lh Ha! Tpbce( ofrs. Mbrof part0crb6 arH&ddd,tr.maLdofr ftluyorlrirdmr, mludiognrortrafrc cmfi.lrs? lFy‐ .explah Aft fiou cErdlyr8r$ftd dpmrned BUI der5tltqr)l lfr'$. lid 3tsl(!) (itrhdhS AI) _ lras rypli@t odrs, ffiberupdbss-aoracd aphmt-r'. mfacts. qtnl*als sdisbiblfq? ■■S NO rr■ ,メ 腱菫く3)a― !L, ry?limr. of66, @Ebces putltr*utcto dafcd * nfrrcda rppticaia fc o*tcrSrp of e $mc1'. nalfrctrrr. rtoleldg. o didributod If )3. Sirt drl{t) & (&r - ■案 N0 懇 N0 ■■S NO ■躊 NO YES NO 留Ъ NO H8 rb. @licer, oficr, m€lobe!. r p{'tea er-r bea issued a lta* to Parr€ piaffilf IfyeB, g$!.l.tdt)& +L! tk lim[ $'s b.a ranc-trmed fi $bjat to di$plie? ヽ■S NO lf !s- nplsin t|Deycnrl j[dgE db6.d.ndfir.trks.druMBultitstmrchinacin&rrtmgpr ilB€dbycym, onir.ina[cg!8rom iatcpr&rarcof ryptmrcycfhmurri$pofr..ilulsiu? YES NO It is aflll'lDed tlrat rll inforumtlon p:or{ded bereiu is tlue eltd con'ect nud li ls lecoSolzed tba! pl'oriditrg felse iufot'matloa tui}' result iu dilcipll|lsll' ection. It is undrrslood thrl lhere uusl be conrplieuce rvllh the pl'ovlslour of lbt Alil,rmx Phernt*c1' Pt'actite Acl, lhe Rulel oflhr Boelrl and rll olher *ppllceble stal$lei. and [ult!. Slgtred く TltleD__… ……………… Dnte_______― ― AppLcatlt's SS REQtIRED AlabaltB 1975 s 30‐ 3‐19■(a) Areド Ш a rS Cit12en'(Cirele)YES ヽO IFNO・ subnit d∝ ume● 1■tl● ュ● f legnl st二 tus in this coull耐 . Subscribed and snam to before ute this day of APPLICA■ 10ヽ ヽ lt‐ SI BEヽ OTRttD. \otarl'Public (Senl) Utds tL{ prc\ili@ of ttre Code of Alabma $il-:l-30, S34-:3-31 e$d Bosrd of Ph.mc}'reulatim 680-X-:- 0Z -=:so Nfi-RBidrd Pbmry shall rhip, mil u delive pnoiptro dogs md tr dsics to s pstat in AL0b@a urds Bgistaed b-v the Atabm St*c Board of Pkrrlr'. Pbsc pmri& th policies ed Fxrdm $81 *t futh t[c rmal &hu1. pnolmk to Alrb@ patrats Em rbe phxnar-r'prcnjdiag phamxy mtcar. R€gistlilioD rrlth the -{lnbama Serrclarl' of State is l'equir'*d. Go to t*ax'.!o3.shte..l.rs for fufiher lnfo
Transcript of ALBOP Files/2020/NRPharmacyApp...Created Date 7/8/2019 10:12:23 AM
For Ottceじ"Onls'
P
まヽ0
Name
Alabama State Bonl・ d ofPhallmaclll Village Steet
Bininghalュ A■ 35242
(205)981‐ 2280
2019/2020 NOヽ RESDEヽT PHARML(:Y想 PLICA■ ON FOR NEW PERMIr
(Vald tbro■_gh 12 31120)
Pel・nlit Fee S750 Colltl・ o■ od Substallces Fee S300.00
Ifyorr do rtot dispcr$e coltrolled substances. urust colrplete Controlled Subsutccs \\:aiver fonu Go to u+r'w.albop.cotu
FEN" Sequndlnthe et・ ent oF晴
"嶽電tO NIPD3)
For ttce VI● Cた
'、
P●ぼ"t■
｀苺:0だeF I
Date
Palust:
Address
Cit、
Toll free phone # Fax * Cell■
Supen'isiug Phan[acist_Alabanra Liceuse =_ErrrailElfectlre 6/9/1,{ - Alabaura licrnsed SP is lequired. See rule 690-\-2-.07 (fl }Iail Ordel Prercrlptious.
Name of owner: (if cupc'ero. *xh ti:r of o6ccn
Alabanu Agent ofRecord: {narne}(Address)________―
― ― ― ― ― ― ― ― ― ― 一 一 一 ― 一 一 ― ― ― ― ― ― ― 一 一 一 一 ― 一 ―
●
h° nel
ha"nf■ぬd腱摯薇ぬ∞雨th the助鳴…
Admttll“ 翅
“
●つLT―m Date Apphed for
to●銀
EB m} ructio s dff1plm1'aaio bm ula regrding ro1' licgu, p€toit c n8lstrreo isscd to $e ryPhed traI 06.11 6 pstns of tb ryplicrt irr-otrug the opmtio c mrathip of a @amy. m&ctu( stok d*, tr dinnbnqlr〕摯,3"statK3D 3-&
村…
…
議曖d睡も藤 desIP●carenged錮薇 shtt be― 鑢appOmnd● ftt S‐餞町●FSute cFtt Sat of施 ぬ四 to be ts…
Pharnacy hours for dispetsing dntgs to Alabanu patieots: Monday - Frida]'_Sat St濾
Noruul nrR around time frorn receipt of prescriptious to shipping drugs to AL patieuts (da)s)_
Procedurc to iollow by AL patieats if nrcdicadon is not arailable or if delivery r'ill be dclayed bcyond a nonnrl delivery time
Procedure to follow for prcscriptions for an acute illncss. to include delitcry at earliest possible linr (i.e. corrier delivery) or altemative toassur. patient the opportunity to obtair mdication at the earliest possible ti$e
Procedurc to follow whcn medicarion is not received aod patient is out ofmcdication aad reguires interim dosage uutil mailed prescriptiondrugs become available
Does rhis facilirypreparE sterilc courpoulds? {checf, all thar rpptyr I f=S[ xo I Non-sterlk t:SP <?95> D Sterlle trSP<?9?>Cortrpkt0 compoundlng qu?stlortrilrcs do!,yllordtd ftom our wrbrllc. SoTE: ruoBtltstlnl omrclru's'rllrbt predrct! & 6l oEpourdlq.
lhHa! Tpbce( ofrs. Mbrof part0crb6 arH&ddd,tr.maLdofr ftluyorlrirdmr, mludiognrortrafrc cmfi.lrs?lFy‐ .explah
Aft fiou cErdlyr8r$ftd dpmrned BUI der5tltqr)llfr'$. lid 3tsl(!) (itrhdhS AI) _lras rypli@t odrs, ffiberupdbss-aoracd aphmt-r'. mfacts. qtnl*als sdisbiblfq? ■■S NOrr■ ,メ腱菫く3)a―
!L, ry?limr. of66, @Ebces putltr*utcto dafcd * nfrrcda rppticaia fc o*tcrSrp of e $mc1'.nalfrctrrr. rtoleldg. o didributod If )3. Sirt drl{t) & (&r
-
■案 N0
懇 N0
■■S NO
■躊 NO
YES NO
留Ъ NOH8 rb. @licer, oficr, m€lobe!. r p{'tea er-r bea issued a lta* to Parr€ piaffilfIfyeB, g$!.l.tdt)&
+L! tk lim[ $'s b.a ranc-trmed fi $bjat to di$plie? ■ヽS NOlf !s- nplsin
t|Deycnrl j[dgE db6.d.ndfir.trks.druMBultitstmrchinacin&rrtmgpr ilB€dbycym, onir.ina[cg!8rom iatcpr&rarcofryptmrcycfhmurri$pofr..ilulsiu? YES NO
It is aflll'lDed tlrat rll inforumtlon p:or{ded bereiu is tlue eltd con'ect nud li ls lecoSolzed tba! pl'oriditrg felse iufot'matloa tui}' resultiu dilcipll|lsll' ection. It is undrrslood thrl lhere uusl be conrplieuce rvllh the pl'ovlslour of lbt Alil,rmx Phernt*c1' Pt'actite Acl, lheRulel oflhr Boelrl and rll olher *ppllceble stal$lei. and [ult!.
Slgtred くTltleD__…………………Dnte_______――
AppLcatlt's SS REQtIRED bycOde ofAlabaltB 1975 s 30‐ 3‐ 19■ (a)
AreドШ a rS Cit12en'(Cirele)YES Oヽ IFNO・ subnit d∝ ume● 1■tl●ュ●f legnl st二tus in this coull耐 .
Subscribed and snam to before ute this day of
APPLICA■10ヽ lヽt‐ SI BEヽOTRttD.\otarl'Public (Senl)
Utds tL{ prc\ili@ of ttre Code of Alabma $il-:l-30, S34-:3-31 e$d Bosrd of Ph.mc}'reulatim 680-X-:- 0Z -=:so Nfi-RBidrd Pbmry shall rhip, mil u delivepnoiptro dogs md tr dsics to s pstat in AL0b@a urds Bgistaed b-v the Atabm St*c Board of Pkrrlr'. Pbsc pmri& th policies ed Fxrdm $81 *tfuth t[c rmal &hu1. pnolmk to Alrb@ patrats Em rbe phxnar-r'prcnjdiag phamxy mtcar.
R€gistlilioD rrlth the -{lnbama Serrclarl' of State is l'equir'*d. Go to t*ax'.!o3.shte..l.rs for fufiher lnfo
The following is g4ip!for non-resident pharmacy application: DO NOT SUBMIT
APPIICATION WITHOUT ALL REQUIRED DOCUMENTS!
1. Home state licenses for !g!! pharmacy and pharmacist
2. Home state license verification for @g! pharmacy and pharmacist
3. Alabama Secretary of State registry (www.sos.al.gov)
4. DEA Certificate (or complete CS Waiver)
5. CS Waiver (if applicable)
6. Board inspection report7. Description of business model/operation and pharmacy type8. Owner/Officer information (Business name w/FEIN#, Officers- Name, SSN, DOB, Home
address and Title
9. Discipline or any FDA 483
For compounding:
10. VPP lnspection report and response (required)
1I.795 and/or 797 questionnaires (on website at www.albop.com)12. List of g[lcompounded medications (dosage form, strength, human or animal use)
13. NIOSH list of meds (if applicable)
14. Beyond use date policy
15. Policy on testing compounds (potency, stability, sterility, & endotoxins)16. Environmental monitoring reports (to include viable and nonviable air flow)
