Louisiana Board of Pharmacy - State of Louisiana

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photo-pharmacist State of Louisiana

Forms & Applications

 Pharmacies

 

Automated Medication System (AMS) Registration 

050 ~ Application for New Automated Medication System (AMS) Registration  


055 ~ Application for Renewal of Automated Medication System (AMS) Registration for Year 2021-2022

055-L ~ Application for Late Renewal of Automated Medication System (AMS) Registration for Year 2021-2022



117 ~ Application for New CDS License for Automated Medication System (AMS)

118 ~ Application for Renewal of CDS License for AMS (or AMX) for Year 2021-2022

118-L ~ Application for Late Renewal of CDS License for AMS (or AMX) for Year 2021-2022


Emergency Drug Kit (EDK) Permit

051 ~ Application for New Emergency Drug Kit (EDK) Permit 


056 ~ Application for Renewal of Emergency Drug Kit (EDK) Permit for Year 2021-2022

056-L ~ Application for Late Renewal of Emergency Drug Kit (EDK) Permit for Year 2021-2022



Louisiana Pharmacy Permit
  (for in-state pharmacies only)
 

053 ~ Application for New Louisiana Pharmacy Permit       

053-S ~ Application for New Hospital Off-Site Satellite Pharmacy Permit 

054 ~ Application for Relocation of Louisiana Pharmacy Permit


058 ~ Application for Renewal of Louisiana Pharmacy Permit for Year 2022

058-L ~ Application for Late Renewal of Louisiana Pharmacy Permit for Year 2022


058-X ~ Application for Renewal of Fee-Exempt Louisiana Pharmacy Permit for Year 2022

058-X-L ~ Application for Late Renewal of Fee-Exempt Louisiana Pharmacy Permit for Year 2022


115 ~ Application for New CDS License for Louisiana Pharmacy


116 ~
Application for Renewal of CDS License for Louisiana Pharmacy for Year 2022


116-L ~ Application for Late Renewal of CDS License for Louisiana Pharmacy for Year 2022



Nonresident Louisiana Pharmacy Permit
  (for pharmacies located outside state)
 

052 ~ Application for New Nonresident Pharmacy Permit   


057 ~ Application for Renewal of Nonresident Pharmacy Permit for Year 2022

057-L ~ Application for Late Renewal of Nonresident Pharmacy Permit for Year 2022


059 ~ Application for Relocation of Nonresident Pharmacy Permit

 

General Purpose Forms

060 ~ Notification of Permanent Closure of Pharmacy Permit  

061 ~ Notification of Change of Pharmacist-in-Charge (PIC) 

063 ~ CDS Inventory Certification Form  

065 ~ Notice of Change of Owner's Managing Officer (OMO) 


450 ~ La. Uniform Prescription Drug Prior Authorization Form



Note:
  If your license or permit has been expired for more than 30 days, it is too late to renew it.  However, you may apply for the reinstatement of the credential.  To do so, please send a written request to the Board office (mail, fax, or email), requesting the information necesssary to reinstate your credential.  Please be sure to include your name, credential number, and current mailing address.  The licensing staff will prepare a reinstatement packet for you, containing instructions on the procedures necessary to reinstate your credential.