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STATE OF ALASKA

DEPARTMENT OF COMMUNITY AND ECONOMIC DEVELOPMENT

DIVISION OF OCCUPATIONAL LICENSING

BOARD OF PHARMACY

P.O. BOX 110806, JUNEAU, ALASKA 99811-0806

(907) 465-2589

E-mail: license@dced.state.ak.us

PROCEDURE TO OBTAIN AN OUT-OF-STATE PHARMACY REGISTRATION

In accordance with AS 08.80.158, a pharmacy located outside of the state that ships, mails, or delivers

prescription drugs to consumers in the state shall register with the board.

NOTE: Please read the application, statues, regulations, and all instructions carefully. It is your responsibility to be aware

of licensing requirements and provide all necessary documentation. The board will not issue a registration until your

application is complete.

APPLICATION FOR REGISTRATION

The following must be on file before the board may review the application for approval:

1. Completed notarized application.

2. Fees required in accordance with 12 AAC 02.310:

$ 50.00 Nonrefundable application fee.

$100.00 License fee.

$150.00 Total required.

3. Names of all owners/principal corporate officers.

4. Name, address and license number of the pharmacist-in-charge and a list of all pharmacists working in the facility.

5. Toll-free telephone number accessible by patients in the State of Alaska.

6. Certified true copy of the valid facility license from the jurisdiction where the facility is located. (NOTE: To obtain a

“certified true copy,” you must present the notary with the original document along with the photocopy. You must write,

“I certify this is a true copy of the original document” and sign your name. The notary will compare the original

document with the copy and then notarize your signature.)

7. Copy of the most recent inspection report from the jurisdiction where the facility is located.

APPLICATION FOR CHANGE OF OWNERSHIP

In accordance with 12 AAC 52.040, when ownership of a pharmacy changes, a new license is required. The existing

license must be returned and a new application, along with the appropriate fees and supporting documentation, must be

submitted. The following must be on file before the board may review the application for approval:

1. Completed application and supporting documentation (see 1 through 7 above).

2. Fees required in accordance with 12 AAC 02.310:

$ 50.00 Nonrefundable application fee.

$100.00 License fee.

$150.00 Total required.

3. Return of the existing Alaska out-of-state license that was issued under the former owner’s application.

APPLICATION FOR CHANGE OF NAME OR LOCATION

In accordance with 12 AAC 52.030, when ownership of a pharmacy changes, a new license is required. The existing

license must be returned and a new application, along with the appropriate fees and supporting documentation, must be

submitted. The following must be on file before the board may review the application for approval:

1. Completed application and supporting documentation (see 1 through 7 above).

2. Fees required in accordance with 12 AAC 02.310:

$ 50.00 Nonrefundable application fee.

$ 5.00 Duplicate License fee.

$ 55.00 Total required.

3. Return of the existing Alaska out-of-state license that was issued under the former pharmacy name or location.

08-4200 (Rev. 7/00)

Form 08-4200 - Procedure To Obtain An Out-Of-State Pharmacy Registration - Alaska Department Of Community And Economic Development

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