Board of Pharmacy Name Change Form

Iowa Board of Pharmacy
400 SW 8th St Ste E
Des Moines, IA 50309
515-281-5944

1. Attach a copy of the legal name change document (ex. marriage certificate, notarized court document, etc.). CSA Registrants Only: Attach a copy of your professional license that reflects the name change has been completed by your primary licensing board.
2. Complete and submit the online form
3. 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

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

Examples of legal name change document are; 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.