6200 Park Ave., Ste. 100 Des Moines, IA 50321
Main Line: 515-281-5944 Fax: 515-281-4609
Iowa Board of Pharmacy 6200 Park Ave., Ste. 100 Des Moines, IA 50321 515-281-5944
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
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)
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
Sign Here
Receipt
