Notice Of Change Of Supervising Pharmacist printable pdf download

Department Use Only

The University Of The State Of New York

The State Education Department

Date Stamp

PH205

Board Of Pharmacy

Email: pharmbd@mail.nysed.gov

Web:

Notice of Change of Supervising Pharmacist

"The state board of pharmacy shall be notified within seven days of any change

in the identity of the supervising pharmacist of a registered establishment. Such

notification shall be made by the owner of the registered establishment." (Rules

Date SP Entered

of the Board of Regents, part 29.7 (a)(10))

Initials

The pharmacy must be supervised by a New York State registered pharmacist at

all times while open. A pharmacy found in violation will be referred to the Office

of Professional Discipline for investigation.

Notes

Instructions: Complete this form and forward to the NYS State Board of Pharmacy by

fax at 518-473-6995, or by mail to 89 Washington Avenue, 2nd Floor West, Albany, NY

12234-1000. Failure to provide complete and accurate information will result in referral

to the Office of Professional Discipline for investigation.

Registered Name of Pharmacy: __________________________________________________________________________

Address of Pharmacy: _________________________________________________________________________________

Pharmacy Registration No.: ___________________________ Registration Period Ending: ________________________

This section must be completed by the Supervising Pharmacist

I, _____________________________________________________________________ , do hereby certify that I replaced

_____________________________________________________________________ as Supervising Pharmacist of the

pharmacy designated above, on _______________________________ (Month/Day/Year).

I do hereby certify that I am a licensed pharmacist, currently registered, holding license number ___________________, dated

___________________, and that I am employed for ____________________ hours a week at this pharmacy.

I further certify that I have full knowledge of my professional responsibilities as Supervising Pharmacist and will discharge my

responsibilities to the best of my ability. This Pharmacy is open for business ____________________ hours each week.

______________________________________________________________________ ______________________________

Signature of Supervising Pharmacist

Date

_____________________________________________________________________

Print Name

______________________________________________________________________ ______________________________

Signature of Proprieter, Corporate Officer, or Authorized Individual (Needs power of attorney) Date

__________________________________________________ _________________________________________________

Print Name

Title

Form PH205, Notice of Change of Supervising Pharmacist, Rev. 4/10

Notice Of Change Of Supervising Pharmacist

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