400 SW 8th St Ste E
Des Moines, IA 50309
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 complete rule for requirements for closing or sale of a pharmacy in 657 IAC 8.35(7).
Please refer to the complete rule for requirements for discontinuing services in Iowa in 657 IAC 19.2(5).
A pharmacy cannot execute a sale or closing of a pharmacy unless there is adequate time prior to the pharmacy's closing for delivery of the notification to the PIC, the Board, the DEA, and the pharmacy patients.
INSTATE PHARMACIES - If you are in possession of any of the following items please contact Melissa Carstens by email (email@example.com) or phone (515-725-3492) to make arrangements for them to be picked up as they are the property of the Iowa Board of Pharmacy:
Does the pharmacy have an active 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 Pharmacy where the pharmacy records are being transferred
Does the pharmacy where the records are being transferred have an active 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 notified by direct mail or personal delivery at least 30 days prior to the pharmacy closing date (657 IAC 8.35(7)"d").
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 for closing or sold pharmacy will be completed at the close of business, including transfer, destruction, and disposal of prescription drugs (657 IAC 8.35(7)"f")
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: