lamphay.bouyavouth@dia.iowa.gov
6200 Park Ave, Ste 100 Des Moines, IA 50321
515.242.5140
This form is intended to assist pharmacies to provide the 30 day prior notification to the Board of the pharmacy's sale, closing, or discontinuation of services in Iowa and to provide a checklist for the pharmacy to ensure complete compliance.
Please refer to the Board's rule for voluntary license cancellation at 481 IAC 551.2(15).
INSTATE PHARMACIES - If you are in possession of any of the following items, please contact the Board of Pharmacy by email (pmp@iowa.gov) to make arrangements for the item(s) to be picked up as they are the property of the Iowa Board of Pharmacy:
Pharmacy Address
Does the pharmacy have an active Iowa Controlled Substance Act Registration (CSA)?
Is the pharmacy permanently closing or being sold? If nonresident pharmacy, discontinuing services in Iowa?
Date of Closing/Sale/Discontinuation of Services in Iowa (must be more than 30 days from today)
A closing pharmacy or nonresident pharmacy discontinuing services in Iowa must ensure that all prescription drugs, prescription files, patient profiles, and controlled substance receipt and disbursement records are transferred to another Iowa licensed pharmacy that agrees to act as custodian of the records for at least two years (657 IAC 8.35(7))
Address of Iowa pharmacy where the pharmacy records are being transferred
Does the pharmacy where the records are being transferred have an active Iowa Controlled Substance Act Registration (CSA) and/or DEA Registration?
Provide the date the PIC of the closing/selling pharmacy was notified (must be at least 40 days prior to the effective date of the sale or closing of the pharmacy, 657 IAC 8.35(7)"a")
Name of the PIC of the purchasing pharmacy
Provide the date that the PIC of the purchasing pharmacy was notified (must be at least 40 days prior to the effective date of the sale, 657 IAC 8.35(7)"a")
Has the DEA been notified of the closing or proposed sale of the pharmacy (657 IAC 8.35(7)"b")?
Provide the date that the DEA was notified or anticipated notification date
Refer to the DEA website for notification procedures and cancellation of 222 Forms and CSOS authorizations.
Patient Notification: Every patient with records of prescriptions filled by the closing/sold pharmacy within the past 18 months, must be given written notice, which may include electronic communication, at least 30 days prior to the pharmacy closing date (481 IAC 551.2(15)(a)(2)
Check the boxes to attest what information was provided in the notices sent to patients
Provide the date that the patient notifications were sent
Provide the date that the public notice was posted at the pharmacy (pick-up locations, including drive-through lanes, store entry and exit doors, and at pharmacy prescription counters, 657 IAC 8.35(7)"d")
Anticipated date that the inventory requirements will be completed at the close of business, including transfer, destruction, and disposal of prescription drugs (481 IAC 553.5(3)
I attest that, within 10 days of closing, the pharmacy will complete the following:
I attest that, within 10 days of the sale, the pharmacy will complete the following:
I attest that, within 10 days of discontinuing services in Iowa, the pharmacy will complete the following:
Sign Here