Pharmacy Emergency Relocation Notification - Initial

In response to a proclamation of disaster emergency or in the event of a natural or man-made disaster, fire, or other occurrence which results in sufficient damage to a pharmacy location as to render it unsafe to operate, a pharmacy may relocate to a temporary or mobile location only in compliance with 657 Iowa Administrative Code 8.35(10). Within one business day of the damage to the pharmacy rendering it unsafe, the pharmacy shall provide notice to the Board of its intent to temporarily relocate pharmacy operations.

Please provide the following information and a Board compliance officer will be notified for follow up. An onsite inspection of the temporary or mobile location will be conducted within five (5) business days of the relocation.

A pharmacy may operate from the temporary or mobile location for no more than six (6) months. If the pharmacy is not able to return to the original licensed location within six (6) months, the pharmacy shall submit an application and fee pursuant to paragraph 8.35(6)”b” prior to the expiration of the six-month temporary relocation period.

The pharmacy shall notify the Board (form available on the Board’s website) of its intent to return pharmacy operations to the original licensed location at least five (5) business days in advance of its return. A Board compliance officer will conduct an onsite inspection of the original licensed location prior to the return of pharmacy operations.

Compliance Officer

Please provide the current pharmacy location information

Pharmacy Name

Pharmacy License No.

CSA Registration No., if applicable

Please identify the type of exceptional circumstance / disaster that warrants the emergency relocation of the aforementioned pharmacy?

If "other" please explain

On what date will the pharmacy be relocating?

Please provide an anticipated duration of operation at the emergency location (a temporary relocation may be valid for no more than 6 months)

If a CSA and DEA registrant, please attest that you have submitted a request to DEA for relocation of your registration as directed by DEA

Yes

N/A

Drug Enforcement Administration (DEA) Emergency Assistance with a Domestic Disaster

If no, please explain why you have not contacted the DEA

Please provide the contact information for the individual who a board compliance officer may contact to coordinate an onsite inspection of the emergency location

Phone Number

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First Name

Last Name

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