NAME CHANGE FOR PHARMACY/DISTRIBUTOR

Permit holders must report when the name of a pharmacy or distributor establishment is changed to ensure that the Board can continue to send important notices; including license renewal information. Failure to provide the Board with a name change or changes in the status of the establishment may lead to Board actions against the permit holder in accordance with HO §12-313(b)(1), (6), (7) and (24), Annotated Code of Maryland.

Please use the form below to notify the Board within 30 days of the change of the name of the establishment.

PLEASE COMPLETE THE ENTIRE FORM

APPLICATION DATE: DATE OF CHANGE:

NEW NAME: PERMIT NUMBER:

PREVIOUS NAME:

ADDRESS:

CITY/STATE/ZIP: COUNTY:

BUSINESS TELEPHONE: BUSINESS FAX:

BUSINESS WEB ADDRESS: eMAIL:

FEDERAL TAX ID #:

Establishments located outside of Maryland:

Does this business currently comply with all licensing requirements in your State? _________

I solemnly affirm that I have met all federal, state and local requirements in changing the name of the pharmacy/distributor permit.

______________________________________________________________________________________________

Signature of Legal Applicant Date

______________________________________________________________________________________________

Typed Name and Title

Mail, Fax or e-Mail form to:

Maryland Board of Pharmacy

4201 Patterson Avenue

Baltimore, Maryland 21215

(410) 764-2485 Telephone (410) 358-6207 Fax

Email Address: MDBOP@DHMH.STATE.MD.US

NOTE: This form may not be used to report location or ownership changes, which requires a fee and new inspection. To acquire the correct form for reporting other establishment changes visit the Board’s web site at www.mdbop.org, then click on ‘Forms & Publications.’

Board Approval: ________________________ Date: _____________________