Fillable ARIZONA STATE BOARD of PHARMACY P.O. Box 18520, (Arizona)

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ARIZONA STATE BOARD of PHARMACY P.O. Box 18520, (Arizona)

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ARIZONA STATE BOARD of PHARMACY
P.O. Box 18520, Phoenix AZ 85005
602-771-2727
NOTIFICATION DOCUMENT TO CLOSE A PHARMACY
(Form to be submitted no later than 14 days prior to closure)
Complete pages 1 and 2 and enclose the current pharmacy permit.
__________________________________________________________________ __________________
Name of Pharmacy Permit Number
__________________________________________________________________ __________________
Address Telephone Number
_____________________________________
DEA Registration Number
NOTE: A final inventory must contain all controlled substances (Original Copy goes with Prescription Invoices)
_____________________ _________________
Closing Date Final Inventory Date
__________________________________________________________________ __________________
Drug Inventory Transferred to Permit Number
__________________________________________________________________ __________________
Address Phone Number
_________________________________________
DEA Registration Number
1. PHARMACY INFORMATION
2. CLOSING INFORMATION
https://pharmacy.az.gov
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__________________________________________________________________ __________________
Drugs for destruction returned to Permit Number
_________________________________________________________________ __________________
Address Phone Number
_________________________________________
DEA Registration Number
__________________________________________________________________ ________________
Prescription files and profiles Records Transferred to (min. of 7 years of records) Permit Number
_________________________________________________________________ ________________
Address Phone Number
_________________________________________
DEA Registration Number
__________________________________________________________________ _______________
Prescription Invoices Transferred to (min. of 3 years of records) Permit Number
__________________________________________________________________ _______________
Address Phone Number
_________________________________________
DEA Registration Number
I hereby attest that the information on this notification document , as well as any attachment(s) to this
document, are to the best of my knowledge true and correct. I agree that any misstatements(s) or omission(s)
as to material facts constitute unprofessional conduct and subject me to the penalties set forth in the Arizona
Statutes and Rules.
________________________________________________________________ ______________
Signature - PIC, Owner, or Managing Officer of the Closing Pharmacy Date
__________________________________________
Type or Print Name
3. ATTESTATION
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(a) Comply with all procedures for Discontinuing a Pharmacy as outlined in R4-23-613.
(b) Return the most current pharmacy permit that was issued to the pharmacy by the Board (if the
permit cannot be located, then send a statement to that effect.);
(c) The pharmacy permittee shall ensure that all pharmacy signs and symbols are removed from
both the inside and outside of the premises.
(d) A.R.S. 36-2523 (B). A person who holds a permit to operate a pharmacy issued under title 32,
chapter 18 shall inventory schedule II, III, IV and V controlled substances as prescribed by federal
law. The permit holder shall conduct this inventory on May 1 of each year or as directed by the
Arizona state board of pharmacy. The permit holder shall also conduct this inventory if there is
a change of ownership or discontinuance of business or within ten days of a change of a
pharmacist in charge.
(e) The name and address of the pharmacy to which the prescription drug orders were transferred.
Mail to:
ARIZONA STATE BOARD OF PHARMACY
P.O. Box 18520
Phoenix, AZ 85005
(f) Send a letter to the appropriate DEA divisional office explaining that the pharmacy has closed.
Include the following items with the letter:
(i) DEA registration certificate;
(ii) All unused DEA Order Forms — write the word “VOID” on the face of each Order Form;
and
(iii) Copy 2 (green) of any DEA Order Forms used to transfer C-II drugs from the closed
pharmacy.
(g) During the seven-year record retention period specified in subsection (A)(4), the person
described in subsection (A)(4) shall provide to the Board upon its request a discontinued
pharmacy’s records of prescription files and patient profiles.
NOTE: It is your responsibility to review all sections that pertain to closing a pharmacy and to be
compliant with those rules.
REMEMBER TO:
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ARIZONA STATE BOARD of PHARMACY P.O. Box 18520, (Arizona)

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Completed 20 July 2020

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