STATE BOARD OF PHARMACY 8 00 SW Jackson, Suite 1414-2026

1. Click ‘Get Form’ to open it in the editor.
2. 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.
3. Provide details for the 'Person Responsible for Pharmacy Closure', including their phone number.
4. In the 'FACILITY RECEIVING PATIENT FILES & RECORDS' section, input the name and registration number of the receiving facility along with their contact information.
5. Next, complete the 'FACILITY RECEIVING REMAINING STOCKS OF DRUGS' section with similar details as above.
6. 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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