Pharmacy Emergency Relocation Notification - Return

A pharmacy operating at an emergency temporary location shall notify the Board of its intent to return pharmacy operations to its original licensed location at least five (5) business days prior to the return.

Please provide the following information and a Board compliance officer will be notified for follow up. An onsite inspection of the original licensed location must be conducted prior to the return of pharmacy operations.

Below you will be requested to identify your assigned compliance officer. If you do not know who your compliance officer is please use this link to identify the compliance officer for your territory.

Compliance Officer

Please provide the following information about the current emergency pharmacy location

Pharmacy Name

Pharmacy License No.

CSA Registration No., if applicable

Please provide the anticipated date of return to the original licensed location. This date must be at least 5 days from the current date.

Please provide the contact information for the individual who a board compliance officer may contact to coordinate an onsite inspection of the original licensed location (note: pharmacy operations may not be returned to the original licensed location until a board compliance officer has conducted an inspection)

Phone Number

Sign Here

First Name

Last Name

Choose how to sign

Draw Type