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Board of Pharmacy Name Change Form

Pharmacists Only: New original license certificates are $20 each, payable by check or money order. Please mail your payment with a request for a duplicate wall license, a copy of this form, and the address where you would like it mailed.

Previous Full Legal Name

First Name

Middle Name

Last Name

New Full Legal Name

First Name

Middle Name

Last Name

Board of Pharmacy License/Registration Type

Board of Pharmacy License/Registration Number

Would you like an updated license/registration certificate emailed to you (this is not to be used for updated pharmacist wall licenses)

Yes

Upload a copy of a legal name change document. Examples: marriage certificate, name change petition, divorce decree (only the page showing the name change is needed).

Do not submit your driver's license or social security card.

Legal Name Change Document

Click Here to Upload

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

Receipt

You will be provided with a Receipt upon submission.

Board of Pharmacy Name Change Form

Previous Full Legal Name

New Full Legal Name

Date of Name Change

Would you like an updated license/registration certificate emailed to you (this is not to be used for updated pharmacist wall licenses)

Legal Name Change Document

Sign Here

Receipt