LIMITED RETAIL DRUG DISTRIBUTOR OF MEDICAL ... - NH . gov - nh 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the location of your facility, including the company name, street address, city, state, and zip code. Ensure all details are accurate for processing.
3. Provide your Federal Tax ID number and email address. If applicable, include the parent company name and state of incorporation.
4. Indicate the nature of your retail business by checking all relevant boxes such as Medical Gas Distributor or Medical Device Distributor.
5. List the types of prescription devices you intend to ship to New Hampshire residents. Be specific about items like Oxygen or Diabetic Testing Supplies.
6. Fill in the contact information for the person responsible for handling the permit application, including their name, title, and business mailing address.
7. Complete the section regarding any past disciplinary actions against your company and provide necessary documentation if applicable.
8. Finally, ensure that you sign and date the application. Attach all required documents before submitting to avoid delays.

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