Iowa Board of Pharmacy

amanda.woltz@iowa.gov

6200 Park Ave., Ste. 100 Des Moines, IA 50321

515-281-5944

Licensee/Registrant Discipline Reporting Form

Licensee/Registrant Name

Iowa License/Registration Number

Address

Address or Location

Phone Number

Email for Contact Person (if different)

Phone Number for Contact Person (if different)

Jurisdiction/Agency Taking Action

Allegations/Charges – provide a summary of the allegations/charges. If it was reciprocal action, provide a summary of the allegations/charges of the originating action. (DO NOT STATE “SEE ATTACHED”).

Provide a summary of the outcome (terms of probation, amount of citation, revocation, duration of sanction, etc.)

Document Upload - document(s) must be the official documents that include information about the allegations and resolution

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First Name

Last Name

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I hereby attest to the accuracy and truthfulness of the information contained herein.