DOH 690-159 December 2013

Pharmacy License Application Packet

Contents:1. 690-159 ..... Contents List/Mailing Information ..................................................1 page

2. 690-160 ..... Application Instructions Checklist ................................................2 pages

3. 690-152 ..... Pharmacy License Application .....................................................3 pages

4. 690-249 ..... NPLEx Account Activation ...........................................................2 pages

5. 690-222 ..... NPLEx Exception Request ..........................................................2 pages

6. 631-020 ..... Prescription Monitoring Program CertificationofNoDispensingofControlledSubstances ............. 1 Page

7. RCW/WACandOnlineWebsiteLinks ...............................................................1 page

In order to process your request:

Mail your application with initial documentation and your check Send other documents not sent or money order payable to: with initial application to:

Department of Health Pharmacy Quality Assurance POBox1099 CommissionCredentialing Olympia, WA 98507-1099 PO Box 47877 Olympia, WA 98504-7877

Contact us: 360-236-4700

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DOH 690-160 December 2013 Page 1 of 2

Application Instructions ChecklistWhenyourapplicationforpharmacylicenseisreceivedbytheDepartmentofHealth,youwillbenotifiedinwritingofanyoutstandingdocumentationneededtocompletetheapplication process.

Indicate type of application—New, change of ownership, change of location, or name change.

• New—First time requesting a pharmacy license.

• Change of Ownership—When name of legal owner/operator changes resulting fromthesaleoflicensedpharmacy.

• Change of Location—Changingthelocationaddressofthepharmacy.Include your current license number.

• Name Change Only—List your current facility name.

F Check One: Pleasecheckyourlegalowner/operatorbusinessstructuretypeaccordingtoyourWashingtonStateMasterBusinessLicense.

F Application Fees: Checkallthatapply;pharmacylocation,controlledsubstanceact,ancillaryutilization(completeadditionalapplication),ordifferentialhours(completeadditionalapplication).Feesarenon-refundable.Youcanchecktheonline fee page for current fees. Note: If you are applying for ancillary utilization you have to complete the ancillary plan and send it in with the application.

F 1. Demographic Information:

UniformBusinessIdentifierNumber(UBI#):EnteryourWashingtonStateUBI#.AllWashingtonStatebusinessesmusthaveUBI#’s.City,county,andstategovernmentdepartmentsalsohaveUBI#’s.

FederalIDNumber(FEIN#):EnteryourFederalIDNumber,ifthebusinesshasbeenissuedone.

Legal Owner/Operator Name: Entertheowner’snameasitappearsontheUBI/Master Business License.

Mailing Address:Entertheowner’scompletemailingaddress.

Phone and Fax Numbers: Entertheowner’sphoneandfaxnumber.

EmailandWebAddress:Entertheowner’semailandagencyWebaddresses,ifthey have them.

Facility/Agency Name: Entertheagency’snameasadvertisedonsigns,brochures or Web sites.

Physical Address: Entertheagency’sphysicalstreetlocationincludingcity,state,zipcode,andcounty.

DOH 690-160 December 2013 Page 2 of 2

Emailaddress:Entertheagency’semailaddressifavailable.

Phone and Fax Numbers: Entertheagency’sphoneandfaxnumber.

Mailing Address: Entertheagency’smailingaddress,ifdifferentthanphysicaladdress.

F 2. Facility Information:

Type of Pharmacy: Please check which type of pharmacy you are applying for; communityretail,hospital,jail,long-termcare,mail-order,nuclear,parenteral,orinternet(includewebaddress).

Hours Pharmacy will be open:EnterhourspharmacywillbeopenMonday-Friday,Saturday,Sunday,andanyholidayhoursthatwillbeopen.

DrugEnforcementAdministration(DEA)RegistrationNumber: Enter the federalDEAregistrationnumberifdispensingcontrolledsubstances.Enter“pending”ifthepharmacyhasnotbeenissueditsDEAregistrationnumber.

Background Questions:Checkyesornoandifyoucheckyes,listandexplainona separate sheet of paper.

Pharmacist in Charge:Enterpharmacistname,licensenumber,anddateofappointment.

F 3. Contact Information:

Entername,title,phonenumber,faxnumber,andemailaddress.

F 4. Additional Information:

Corporation information:Enterdateofincorporation,corporatenumber,andstateof corporation.

Legal Owner:Listthenames,titles,addresses,andphonenumbersofthecorporateofficers,partners,members,andmanagers.Attachadditionalcompletedpagesifyouneedmorespace.

Change of Ownership Information: List the previous legal owner name, previous nameoffacility,previouslicensenumber,andeffectivedateofownershipchange.

List of Pharmacists: List all pharmacists working in your pharmacy. Attach additionalcompletedpagesifyouneedmorespace.

F Signature:

Signatureoflegalownerorauthorizedrepresentative.

Datesigned.

Printnameoflegalownerorauthorizedrepresentative.

Printtitleoflegalownerorauthorizedrepresentative.

F Pharmacy Location .............................FeeF ControlledSubstanceAct ....................FeeF AncillaryUtilization ..............................Fee(Completeadditionalapplication)F Differential Hours ................................Fee(Completeadditionalapplication)

Check the online fee page for current feesAllapplicationfeesarenonrefundable.

DateStampHere

Fees (Check all that apply)

Revenue: 0262010000

DOH 690-152 December 2013 Page 1 of 3

1. Demographic Information

Check One

UBI# FederalTaxID(FEIN)#

Legal Owner/Operator Name

MailingAddress

City State ZipCode County

Facility/AgencyName(BusinessnameasadvertisedonsignsorWebsite)

FacilityPhone(enter10digit#) Fax(enter10digit#)

Phone(enter10digit#) Fax(enter10digit#)

City State ZipCode County

PhysicalAddress

City State ZipCode County

MailingAddress(Ifdifferentthanphysicaladdress)

EmailAddress WebAddress:

F AssociationF CorporationF FederalGovernmentAgencyF LimitedLiabilityCompanyF LimitedLiabilityPartnership

F LimitedPartnershipF Municipality (City)F Municipality (County)F Non-ProfitCorporationF Partnership

F SoleProprietorF StateGovernmentAgencyF TribalGovernmentAgencyF Trust

Thisisfor:F New F Change of Ownership F Change of Location – Current License # __________ F Name Change Only – Current Facility Name ______________________________________

Pharmacy License Application

EmailAddress:

2. Facility Information

3. Contact Information

DOH 690-152 December 2013 Page 2 of 3

DateofIncorporation CorporateNumber StateofCorporation

ContactPerson Phone(enter10digit#) EmailAddress

Monday–Friday Saturday Sunday Holidays

ContactPerson Phone(enter10digit#) EmailAddress

Name Address Phone(enter10digit#) Title

Name Title

Name Title

4. Additional Information

Legal Owner Information–attach additional completed pages if you need more space.

Pharmacy Hours—Indicatethehoursthepharmacywillbeopen

1. Haveanyapplicants,partners,ormanagershadasuspension,revocation,orrestriction of a professional license? .........................................................................................................................F F

Ifyes,listandexplainonaseparatesheetofpaper.2. Haveanyapplicants,partners,ormanagersbeenfoundguiltyofadrugorcontrolled

substance violation? .................................................................................................................................F F

Ifyes,listandexplainonaseparatesheetofpaper.

Background Questions YesNo

Listnames,addresses,phonenumbers,andtitlesofcorporateofficers,partners,membersandmanagers.

Type of PharmacyF Community/Retail F Hospital F Jail F Long-term Care (LTC)FMail-Order F Nuclear F Parenteral F Internet FCompounding

DrugEnforcementAdministration(DEA)RegistrationNumber

Pharmacist in Charge License Number Date of Appointment

Pharmacist in Charge

DEANumber:_____________________________________

DOH 690-152 December 2013 Page 3 of 3

Name License #

List all Pharmacist–attach additional completed pages if you need more space.

Signature

IcertifyIhavereceived,read,understood,andagreetocomplywithstatelawandruleregulatingthislicensingcategory.Ialsocertifytheinformationhereinsubmittedistruetothebestofmyknowledgeandbelief.

SignatureofOwner/AuthorizedRepresentativeofPharmacy Date

Print Name Print Title

Previous Name of Legal Owner

Previous Name of Facility Previous Pharmacy License # Effective Date of Ownership Change

Change of Ownership Information

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Pharmacy Quality Assurance Commission PO Box 47877 Olympia, WA 98504-7863 360-236-4700

Washington State Methamphetamine Precursor Electronic Tracking System

NPLEx Account Activation

In2010theWashingtonLegislaturepassedRCW69.43.110torestrictthesaleandpurchaseofnon-prescriptionproductscontainingephedrine,pseudoephedrine,andphenylpropanolamineortheirsaltsor isomers, or salts of isomers.

Thelaw:

• Requirespharmaciestokeepproductscontainingmethamphetamineprecursorsbehindthecounterwherethepublicisnotpermittedorinalockeddisplaycasewhereitisnotaccessible to customers without assistance;

• Requirestheretailertorecordthenameandaddressofthepurchaser,thedateandtimeofthesale,thenameandtheinitialsofthepersonconductingthetransaction,thenameoftheproductsold,andthetotalquantityingramsoftheprecursorsbeingsold;

• Requiresthecustomertoelectronicallyormanuallysignarecordofanytransactionswhenpurchasing methamphetamine precursors;

• Updatesthesaleslimitstomatchthefederalrestrictions-dailysaleslimitof3.6gramsperpurchaserandprohibitsapurchaserfrombuyingmorethanninegramsduringa30-dayperiod;and

• Requires the Pharmacy Quality Assurance Commission to implement a real-time electronic sales tracking system.

* Rules:WAC246-869-070through120

Note:Ifyourpharmacysellsephedrine,pseudoephedrine,and/orphenylpropanolamineoverthecounter,youwillneedtosetupanaccounttoaccessandreporttotheNationalPrecursorLogExchange(NPLEx)byvisiting:https://nplex.appriss.com.

DOH 690-249 December 2013 Page 1 of 2

Notification to the commission of Pharmacy Opting Out of Electronic Reporting - NPLEx

Pleaseprovidetheinformationrequestedbelow(printortype.)

Name of Pharmacy Washington Pharmacy License Number

Address City State ZipCode

EmailAddress Phone(enter10digit#)

Name of Pharmacy Responsible Manager License Number of

NameofPersonCompletingform SignatureandDate

BysigningthisformIcertifythattheaforementionedpharmacy:

F Doesnotcurrentlysell,transfer,ortootherwisefurnishover-the-counterephedrine,pseudoephedrine,and/orphenylpropanolamineproducts.

F Currentlysells,transfers,orotherwisefurnishesephendrine,pseudoephedrine,and/orphenylpropanolaminecontainingproductsbyprescriptionsonly.

F Meets the exemption in RCW69.43.110andhassubmitteddocumentationtoshowgoodcausewhycompliancewiththeelectronicreportingwouldbeasignificanthardship.Apaperlogisbeingmaintainedpendingcommissionapproval.

Additionalcomments:

DOH 690-249 December 2013 Page 2 of 2

Thisisarequestforan:FOriginalExemptionRequest LengthofExemption(nottoexceed180days):____________________FExtensionRequest LengthofExemption(nottoexceed180days):____________________

Washington Methamphetamine Precursor Electronic Retail Sales Tracking System

Pharmacy Quality Assurance Commission PO Box 47877 Olympia, WA 98504-7863 360-236-4700

RequestforExemptionRevisedCodeofWashington69.43.110providesanexemptionfromtheWashingtonMethamphetaminePrecursorElectronicRetailSalesTrackingSystem(NPLEx)reportingrequirementsforretailersthatcanshowgoodcausewhytheycannotcomply.RetailerswhobelievetheyareeligibleunderthisprovisionmayapplyforanexemptionwiththeWashingtonStatePharmacyQualityAssuranceCommission.Torequestanexemptionfrom compliance, complete all of the following information along with the signature of the retailer or person authorizedbytheretailer.Thecommissionwillreviewtherequestforexemptionandwillgrantordenytherequestwithin15businessdaysfromreceipt.Good causeconveysmustshowsignificanthardshiptocomplyasprescribedbylaw.Whatconstitutesagoodcausewillbedeterminedonacase-by-casebasis.Goodcause,includesbutisnotlimitedto,situationswherethe installation of the necessary equipment to access the system is unavailable or cost prohibitive to the retailer.

Credential Type:

FPharmacy CredentialNumber/DEACMEACertID_______________________________________ FItinerantVendor CredentialNumber/DEACMEACertID_______________________________________ FShopkeeper(endorsement) UBINumber/DEACMEACertID____________________________________________

Demographic Information:Legal Owner/Operator Name

MailingAddress

City State ZipCode County

Phone(enter10digit#) Fax(enter10digit#)

EmailAddress WebAddress

Facility/AgencyName(BusinessnameasadvertisedonsignsorWebsite)

City State ZipCode County

PhysicalAddress

Facilityphone(enter10digit#) Fax(enter10digit#)

MailingAddress(ifdifferentthanphysicaladdress)

DOH 690-222 December 2013 Page 1 of 2

Date Stamp Here

EmailAddress WebAddress

IattestthatIhavereceived,read,understood,andagreetocomplywithstatelawandruleregulatingthislicensecategory.Ialsoattestthattheinformationhereinsubmittedistruetothebestofmyknowledgeandbelief.Ialsounderstandthatthebusinessisrequiredtokeepawrittenlogofallpurchasetransactionsinvolvingrestrictedproductstoincludethefollowing:Dateandtimeofpurchase,productdescription;quantitysold(totalgrams,numberofboxes,etc.);purchaser’sfullname,dateofbirth,currentaddress,formofidentificationusedtoestablishage;identificationformnumber;purchaser’ssignatureandinitialsofthepersonmakingthesale.

__________________________________________________________ _____________________________

__________________________________________________________ _____________________________

SignatureofOwner/AuthorizedRepresentative Date(mm/dd/yyyy)

Print Name Print Title

DOH 690-222 December 2013 Page 2 of 2

Please send request to the address above.

JustificationforExemption: (includeadditionalsheetsandsupportingdocumentationifneededtoshowgoodcause)

Signature

Prescription Monitoring Program P.O. Box 47852Olympia WA 98507-7852360-236-4806prescriptionmonitoring@doh.wa.gov

DOH 631-020 May 2016

No Dispensing of Controlled Substances Registration

IfyourpharmacydoesnotdispensecontrolledsubstancestoWashingtonStateresi-dents,youcancompletetheNoDispensingofControlledSubstancesregistrationonlineandsubmitittothedepartment.Ifthedepartmentapprovesyourrequest,yourpharma-cywillnothavetofilezeroreportsforcompliancepurposes.Youwillneedtoresubmitthe registration each year when you renew your pharmacy license. By submitting an NDCSregistrationyou’llbecertifyingthat:

• Mypharmacydoesnotcurrentlydeliveranydrugscoveredbytheprogram(scheduleII,III,IV,orVcontrolledsubstancesoranyotherdrugsaddedbythePharmacyCommission)toultimateuserswhohaveaWashingtonStateaddress.

• IfourbusinesspracticechangesregardingdispensingdrugscoveredbytheprogramtoultimateuserswithaWashingtonStateaddress,wewillnotifytheWashingtonStateDepartmentofHealthandbegindatasubmissionasrequiredinRCW70.225.

• My pharmacy will resubmit this form every year with our pharmacy license renewal inordertore-certifythatthepharmacydoesnotdeliveranydrugscoveredbytheprogramtoultimateuserswhohaveaWashingtonStateaddress.

TheNDCSregistrationcanbeaccessedatwww.wapmp.org.Lookunderthe“WAPharmacy/PrescriberDataUploader”linkinthemenuontheleftofthepageandthenthe“NoDispensingofControlledSubstances”link.

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RCW/WAC LinksUniform Disciplinary Act, RCW18.130

UniformControlledSubstanceAct,RCW69.50

Administrativeproceduresandrequirements,WAC246-12

StandardsofProfessionalConduct,WAC246-16

PharmacyLaws,RCW18.64

PharmacyRules,WAC246-869

PharmaceuticalServices-ExtendedCareFacility,WAC246-865

HospitalStandards,WAC246-873

NuclearPharmaciesandPharmacist,WAC246-903

Pharmacy-AncillaryPersonnel,WAC246-901

LegendandPrescriptionDrugs,RCW69.41

PrecursorDrugs,RCW69.43

Pharmaceutical-PrecursorSubstance,WAC246-889

RegulationsImplementingtheUniformControlledSubstanceAct,WAC246-887

PrescriptionMonitoringProgramLaws,RCW70.225.020

PrescriptionMonitoringProgramRules,WAC246-470

On-LineAIDSTrainingResources,ReferencePage

PharmacyQualityAssuranceCommission,WebPage

RCW/WAC and Online Web Site Links

RCW/WACandOnlineWebSiteLinksDecember2013