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How to use or fill out STATE BOARD OF PHARMACY 800 SW Jackson, Suite 1414
- Click ‘Get Form’ to open it in the editor.
- Begin by filling in the 'CLOSING FACILITY' section. Enter the facility's name, Kansas registration number, physical address, closure date, city, state, zip code, and county. Indicate whether the facility holds a Retail Dealer Permit.
- Provide details for the 'Person Responsible for Pharmacy Closure', including their phone number.
- In the 'FACILITY RECEIVING PATIENT FILES & RECORDS' section, input the name and registration number of the receiving facility along with their contact information.
- Next, complete the 'FACILITY RECEIVING REMAINING STOCKS OF DRUGS' section with similar details as above.
- Finally, ensure you fill out the 'OWNER CERTIFICATION' section by signing and dating the form. Include your printed name and email address.
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