Fillable Notice of Change of Pharmacist-in-Charge (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Notice of Change of Pharmacist-in-Charge (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Board of Pharmacy
124 Halsey Street, 6th Floor, P.O. Box 45013
Newark, New Jersey 07101
Notice of Change of Pharmacist-in-Charge
Whenever a registered pharmacist assumes or terminates the duties as a registered pharmacist-in-charge of a pharmacy, both the outgoing
and incoming pharmacist-in-charge, and the permit holder shall so advise the Board in writing within 30 days by completing this form
and mailing it to the address above.
If there is a vacancy of the pharmacist-in-charge for longer than 30 days, the interim pharmacist-in-charge and the permit holder must
notify the Board immediately of who shall act as the interim registered pharmacist-in-charge.
Pharmacy Information
Pharmacy Permit Number  Pharmacy’s telephone number __________________________
Include area code
Name of pharmacy ____________________________________________________________________________________________
Address of pharmacy __________________________________________________________________________________________
Street address City ZIP code
Permit holder’s name ____________________________________ Permit holder’s telephone number _________________________
Print name Include area code
Pharmacist-in-Charge Information

Full name ________________________________________________ License number _____________________________________
Print name
Last date as PIC _____________________________ Date outgoing CDS inventory completed _______________________
Signature ________________________________________________________ Date ______________________________
Permit holder’s signature ___________________________________________ Date ______________________________
Note: If the  pharmacist-in-charge is not available, follow the instructions in N.J.A.C. 13:39-6.2(d)(1).

Full name ________________________________________________ License number _____________________________________
Print name
Start date ___________________________________ Date incoming CDS inventory completed _______________________
Signature ________________________________________________________ Date ______________________________
February 2018
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New Jersey Ofce of the Attorney General
Division of Consumer Affairs
Board of Pharmacy
124 Halsey Street, 6th Floor, P.O. Box 45013
Newark, New Jersey 07101
Incoming Pharmacist-In-Charge Acknowledgement
I agree to assume the duties and responsibilities of the pharmacist-in-charge at the above pharmacy and am aware
of my personal liability for violations of any New Jersey Pharmacy laws. I am aware of the need to inventory
Controlled Dangerous Substances as required by law, including at the time I assume the position of pharmacist-
in-charge and when I resign this position.
In addition to the requirements all pharmacists must meet, a pharmacist-in-charge has a specic set of additional
responsibilities. The pharmacist-in-charge is responsible for all activities that occur in his or her pharmacy practice
site. Any violation or oversight is ultimately the pharmacist-in-charge’s responsibility.
I have read and understand the duties and responsibilities of a pharmacist-in-charge as set forth in the New Jersey
Pharmacy Practice Act (N.J.S.A. 45:14-40 et seq.) and the New Jersey Board of Pharmacy regulations (N.J.A.C.
13:39).
____________________________________ ______________________________
Pharmacist-in-Charge signature Date
Permit holder’s signature ___________________________ Date ______________________
February 2018
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Notice of Change of Pharmacist-in-Charge (State of New Jersey, Dept. of Law & Pub. Safety, Office of the Attorney General)

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Completed 15 August 2020

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