Submit Request For Address

                Submit Request For Address / Employer Change
Use this form to change your pharmacist or technicians address or employer information
Do not use this form for a Duplicate License or Registration a fee is required for Duplicates

Allow 7-10 days for processing

License / Registration or Candidate # Candidate #    or   License/Registration #

Name

New Home Address

City

State

Zip Code

Home Telephone #

Cell #

Employer Maryland Pharmacy Permit Number   (Example: P04055 or PW0123)

Employer Name

Employer Address

Employer City

Employer State

Employer Zip Code

Business Telephone #

Business Fax Telephone #

Email the Confirmation to

License / Registration or Candidate #	Candidate # or License/Registration #
Name
New Home Address
City
State
Zip Code
Home Telephone #
Cell #
Employer Maryland Pharmacy Permit Number	(Example: P04055 or PW0123)
Employer Name
Employer Address
Employer City
Employer State
Employer Zip Code
Business Telephone #
Business Fax Telephone #
Email the Confirmation to