Iowa Limited Distributor Facility Manager Change Notification

Iowa Board of Pharmacy
6200 Park Ave., Ste. 100
Des Moines, IA 50321
susan.wennekamp@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

Business Name (name in which company is doing business)

Legal Name (if different)

Iowa License Number

Federal Tax ID#

NABP e-profile ID#

Phone Number

Alternative Phone Number

Website

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

Effective Date of Change

Full Legal Name

First Name

Middle Name

Last Name

Previous Name(s) Used

Phone Number

Alternative Phone Number

Facility Manger Email

Date of Birth

Social Security Number

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

Click Here to Upload

Facility Manager Attestations

As Facility Manager, I attest that I have adequate experience in prescription drug and device distribution, as applicable, and am actively involved in the daily operation of the distribution facility. I have and will maintain functional understanding of federal and state laws, rules, and regulations pertaining to drug and device distribution, as applicable.

I hereby swear or affirm that I have no felony convictions or convictions related to prescription drug and device distribution including distribution of controlled substances

Facility Manger Signature

First Name

Last Name

Choose how to sign

Draw Type

I hereby swear or affirm under penalty of perjury that the information provided in this application is true and correct. I understand that failure to provide complete and truthful information may constitute grounds for denial revocation, or other disciplinary sanctions against the facilities license(s).