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 2017-2018

055-L ~ Application for Late Renewal of Automated Medication System (AMS) Registration for Year 2017-2018

055-X ~ Application for Renewal of Fee-Exempt Automated Medication System (AMS) Registration for Year 2017-2018

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

118 ~ Application for Renewal of CDS License for AMS (or AMX) for Year 2017-2018

118-L ~ Application for Late Renewal of CDS License for AMS (or AMX) for Year 2017-2018

 

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 2017-2018

056-L ~ Application for Late Renewal of Emergency Drug Kit (EDK) Permit for Year 2017-2018

056-X ~ Application for Renewal of Fee-Exempt Emergency Drug Kit (EDK) Permit for Year 2017-2018

 

Louisiana Pharmacy Permit  (for in-state pharmacies only) 

053 ~ Application for New Louisiana Pharmacy Permit   (Revised 06-01-2017)    

054 ~ Application for Relocation of Louisiana Pharmacy Permit


058 ~ Application for Renewal of Louisiana Pharmacy Permit for Year 2017

058-L ~ Application for Late Renewal of Louisiana Pharmacy Permit for Year 2017


058-X ~ Application for Renewal of Fee-Exempt Louisiana Pharmacy Permit for Year 2017

058-X-L ~ Application for Late Renewal of Fee-Exempt Louisiana Pharmacy Permit for Year 2017


115 ~ Application for New CDS License for Louisiana Pharmacy


116 ~ Application for Renewal of CDS License for Louisiana Pharmacy for Year 2017

116-L ~ Application for Late Renewal of CDS License for Louisiana Pharmacy for Year 2017


Non-Resident Louisiana Pharmacy Permit  (for non-resident pharmacies only) 

052 ~ Application for New Non-Resident Pharmacy Permit   (Revised 06-01-2017)


057 ~ Application for Renewal of Non-Resident Pharmacy Permit for Year 2017

057-L ~ Application for Late Renewal of Non-Resident Pharmacy Permit for Year 2017


059 ~ Application for Relocation of Non-Resident Pharmacy Permit

 

General Purpose Forms

060 ~ Notification of Permanent Closure of Pharmacy Permit

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

062 ~ Affidavit of Acknowledgement and Acceptance of Responsibility by Pharmacist-in-Charge  [Required only once to obtain PIC privilege.]

063 ~ CDS Inventory Certification Form

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

201 ~ Product Order Form - Duplicate Credential


Note:
  If your license or permit has been expired for more than 30 days, it is too late to renew it.  However, you can 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.