Skip to form

Iowa Board of Pharmacy

400 SW 8th St. Ste E Des Moines, IA 50309

Main Line: 515-281-5944 Fax: 515-281-4609

image

Board of Pharmacy Name Change Form

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

New Full Legal Name

Date of Name Change

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

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

Sign Here

Choose how to sign

Receipt

You will be provided with a Receipt upon submission.