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Pharmacy-discont

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Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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The Commonwealth of Massachusetts
Department of Public Health
Bureau of Health Professions Licensure
Board of Registration in Pharmacy
239 Causeway Street, Suite 500, 5
th
Floor
Boston, MA 02114
(800) 414-0168 (office) / 617-973-0983 (fax)
http://www.mass.gov/dph/boards/ph
Pharmacy Initial Closing Notice
To be submitted at least 14 days prior to closing
Name of Pharmacy:
License No:
Address of Pharmacy:
City:
Manager of Record:
MOR License No.
Telephone Number:
Email:
Anticipate Closing Date:
Intended procedures for closing the pharmacy, including customer notification:
Receiving Pharmacy: (name, address, phone number)
Receiving Pharmacy License No.
Manager of Record of the Receiving Pharmacy
Licensed No.
The Commonwealth of Massachusetts
Department of Public Health
Bureau of Health Professions Licensure
Board of Registration in Pharmacy
239 Causeway Street, Suite 500, 5
th
Floor
Boston, MA 02114
(800) 414-0168 (office) / 617-973-0983 (fax)
http://www.mass.gov/dph/boards/ph
Pharmacy Final Closing Notice
This form is to be submitted within 10 days of closing
Please enclosed your license cards with this form
Name of Pharmacy:
License No:
Address of Pharmacy:
City:
Manager of Record:
MOR License No.
Telephone Number:
Email:
Actual Closing Date:
Receiving Pharmacy: (name, address, phone number)
Receiving Pharmacy License No.
Date transfer took place:
Manager of Record of the Receiving Pharmacy
Licensed No.
I attest that all controlled substances have been transferred or disposed of in accordance with federal regulations.
MOR Name:____________________________________________________________________
MOR Signature________________________________________________Date______________
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Pharmacy-discont

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Completed 3 February 2020

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