Wisconsin Pharmacy Closing Affidavit

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Wisconsin Department of Safety and Professional Services
Mail To:
P.O. Box 8935
1400 E. Washington Avenue
Madison, WI 53708-8935
Madison, WI 53703
FAX #:
(608) 261-7083
E-Mail: web@dsps.wi.gov
Phone #:
(608) 266-2112
Website:
PHARMACY EXAMINING BOARD
PHARMACY CLOSING AFFIDAVIT
CHANGE OF OWNERSHIP
OUT OF BUSINESS
CHANGE OF LOCATION
REMODEL
Closing Date: ______________________________________________
Please TYPE or PRINT in INK
I hereby certify the below named pharmacy closed on ____________________________ and the following action was taken:
(date)
PHARMACY: _________________________________
LICENSE #:
_________________________________
ADDRESS:
_________________________________
Managing R.Ph. _________________________________
number, street
License #:
_________________________________
_________________________________
city, state, zip code
Contact Phone #: _________________________________
ALL NON-CONTROLLED PRESCRIPTION DRUGS
TRANSFERRED PRESCRIPTION FILES TO:
REMOVED FROM PREMISES AND RECEIVED BY:
NAME:
_________________________________
NAME:
_________________________________
ADDRESS:
_________________________________
ADDRESS:
_________________________________
_________________________________
_________________________________
LICENSE #:
_________________________________
LICENSE #:
_________________________________
ALL CONTROLLED DRUGS SUBJECT TO FEDERAL CONTROLLED SUBSTANCES ACT DISPOSED OF
IN ACCORDANCE WITH 21 CFR 1307.21.
Transferred to:
Name:
_________________________________________________________________________________________
Address: _________________________________________________________________________________________
Date of Final Inventory ________________________________________________________________________________
Date of Transfer
______________________________________________________________________________
FED. CSA REG. NO. ______________________________________________________________________________
DEA Form #222
______ YES
_______ NO
1.
Removed all drug signs and all symbols, insignia, etc., indicating the presence of a pharmacy. (For out of business
pharmacies only. Not required for remodel requests.)
______ YES
______ NO
_______ N/A
If yes, date: __________________________________
#606 (Rev. 11/11)
-OVER-
Ch. 450, Stats.
Committed to Equal Opportunity in Employment and Licensing

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