Form online 2026

1. Click ‘Get Form’ to open it in our editor.
2. Begin with Section 1: Company Information. Fill in the pharmacy's name, FEIN or SSN, physical location, and contact details including phone and fax numbers.
3. Proceed to Section 2: Pharmacist in Charge Information. Enter the name and license number of the new pharmacist in charge, along with their contact address and expiration date.
4. In Section 3, specify the effective date of the change and provide the name of the current pharmacist in charge being replaced.
5. Complete Section 4 by listing all pharmacy technicians employed at your pharmacy. Ensure you include their names, license numbers, and expiration dates.
6. Review Sections 5 through 9 for any additional required information or waivers that may apply to your application.
7. Finally, sign Section 10 to affirm that all information is accurate before submitting your application.

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