DOWNLOADS

Instructions: Click on the name of the application and it will open, then click SAVE to place it on your computer

PHARMACY
New and Renew Application

WAIVER
New and Renewal Application

NON-RESIDENT
New and Renewal Application

DISTRIBUTOR
 Wholesale Distributor
Manufacturer of own Product

INSPECTION
 Community Pharmacy Inspection Form

 Distributor Inspection Form

Hospital Inspection Form

Long Term Care Inspection Form

Sterile Inspection

Opening Pharmacy Inspection Form

Repository Inspection Form

 

OTHER
Drug Repository

Donor Form

Repository Recipient

Law Book Order Form (fee) 

Name Change Only

Roster Request Form

Report or view missing or stolen prescription pads - Click Here

Duplicate License Form

Written Verification Form

 


ESTABLISHMENT FORMS

NEW FEE INCREASES EFFECTIVE FEBRUARY 1, 2010

 

 Pharmacies Stop! Please read the important renewal information

                      -    Please Read This  Important **  NOTICE   **

                      -   WHOLESALE DISTRIBUTOR APPLICATION

                      -   DISTRIBUTORS MANUFACTURING THEIR OWN PRODUCT

                       -  SAMPLE SURETY BOND and
                           SAMPLE IRREVOCABLE LETTER of CREDIT

                       -  FAQs

 

Click the links on the left to download the application to your computer.

The Board is in the process updating the establishment forms, enter your contact information and check the appropriate box to request that a new form be mailed  or emailed to you Microsoft Word.  

                Submit Request For Establishment Information
           Allow 7-10 days for processing
Name  
Company Name  
Address 
City 
State 
Zip Code 
Home Telephone # 
Business Telephone #
Email the Information to  
Enter "Do Not eMail" if you wish to have the information mailed to the address above. Criminal Background cards can not be emailed.

Information Requested 

       Pharmacy Permit Forms

   New Pharmacy Application

   Pharmacy Reinstatement Application 

   Pharmacy Change Owner/Location      

   Pharmacy Name Change Only Form 

   Pharmacy Repository / Drop-off Application 

   New Pharmacy Non-Resident Application

   New Pharmacy Waiver Application 

 

      Distributor Permit Forms

   Wholesale Distributor Application

    Own-Label Distributor Application 

   Distributor Reinstatement Application      

   Distributor Change Owner/Location 

   Distributor Name Change Only Form  

 

        Other Forms

   Criminal Background Application Only     

   Request Closing Inspection Form 

  

Permit #  Include if you currently have a Maryland permit

 

     RETURN TO  HOME PAGE

Board Pharmacy Pharmacist Contact Information
4201 Patterson Avenue  
Baltimore, Md 21215
(410)764-2485
(410)358-6207 (fax)

    Contact:  Keisha Wise        KLWISE@dhmh.state.md.us

   Last  Updated:  12/02/2011