Skip to form

Iowa Board of Pharmacy

cassie.lee@iowa.gov

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

515-242-3272

Board of Pharmacy logo

Iowa Limited Distributor Facility Manager Change Notification

Iowa Board of Pharmacy
400 SW 8th St Ste E
Des Moines, IA  50309
deborah.mcclure@iowa.gov
515-242-3272

657 IAC 42.3(8) requires that a limited distributor provide notice to the Board within 10 days of the change in facility manager.

Facilities managers must upload a copy of their government issued identification and resume.

Licensee Information

Facility Address (physical location of establishment which should be reflected on all sales invoices and shipping documents)

Mailing Address (where all correspondence regarding licensure will be sent if other than facility address)

Facility Manager - the facility manager is the individual responsible for the day-to-day operations of the limited distributor

Effective Date of Change

Date Picker

Full Legal Name

Address

Date of Birth

Date Picker

Document Upload - Attach the Facility Manager's Resume and Government Issued Identification

Click Here to Upload

Facility Manager Attestations

Facility Manger Signature

Choose how to sign