USVI Public Records

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Application for a Virgin Islands Pharmacy License Virgin Islands Board of Pharmacy Type or clearly print (all blanks must be completed - if not applicable, enter N/A) VI BOP USE ONLY Application fees are non-refundable. Applications are valid for 1 year from the date of receipt of the ORIGINAL application The ORIGINAL completed application, ORIGINAL supplemental forms all required attachments shall be mailed to: Virgin Islands Dept of Health, Office of Professional Licensure, P.O. Box 222995, Christiansted, VI 00822 The required fees must accompany the application. Make check payable to " Government of the Virgin Islands" IMPORTANT: once the review of the application begins for new pharmacies, the application will be CANCELLED if there is: Change in Ownership Change in Managing Officer (i.e.. Additional and/or removal of an officer, or a Change in Location for the pharmacy If this occurs, then the applicant must reapply for the license by submitting a new application packet and fee to the Board. Name of Pharmacy: Type of Application and Fees (Check Appropriate Box) New Pharmacy ($575) Remodeling of Prescription Department ($350) Change of Ownership ($180) Change in Pharmacist-in-Charge ($180) Effective date of Change Effective date of Change Previous Legal Name (Corp. LLC, etc.) Name of Previous Pharmacist-in-Charge Previous Pharmacy Name Change in Location ($350) Previous Physical Address Previous Location Previous Mailing Address Change in Pharmacy Name (No Fee) Reinstatement due to Lapse of Permit (call Board) Effective date of Change Reinstatement due to Suspension or Revocation of Permit (call Board) Previous Name If this application is for a New Pharmacy, Change in Location, or the Remodeling of Prescription Department, what is the anticipated date of opening? ________________________ Inspections are required for the following applications: New Pharmacy, Change in Location, and Remodeling of Prescription A minimum of 20 business days is required for scheduling an inspection. No drugs may be stocked prior to inspection and approval. The responsible person shall review pharmacy checklist to ensure the readiness of the pharmacy for inspection. The inspector will contact the responsible person prior to the requested inspection date to confirm readiness. If the inspector does not contact the responsible person at least 2 business days before the scheduled inspection, the responsible person shall contact the Board's office at (340) 774-7477 Ext 5694 on St. Thomas or (340) 718-1311 on St. Croix. Pharmacy Information Contact Information Legal Name (Corp. LLC, etc.) Pharmacy Name Physical Address Street Address City State Zip Code Mailing Address Street Address City State Zip Code Pharmacy Phone Number Pharmacy Fax Number Federal Employment Identification Number (FEIN) DEA Registration Number Web Address Email Address Type of Ownership Corporation Limited Liability Company (LLC) Individual/ Sole Proprietorship Partnership Other (specify): _________________________________ Type of Pharmacy Community - Independent Hospital / Institutional Community - Multi/Chain Other (specify) ______________________ Description of Services - Check All That Apply - Must Indicate at Least 1 Type of Service 24 Hour Service Compounding, Non-Sterile* Closed Door Compounding, Office Use Compounding Sterile, LOW Risk Home Delivery Compounding Sterile, MED Risk Infusion Compounding Sterile, HIGH Risk Shipping Prescriptions / Mail Order Inpatient Prescriptions Veterinary Prescriptions Outpatient Prescriptions Nuclear 503B Outsourcing Facility Other (specify):_____________________ Pharmacist Administered Immunizations __________________________________ * Do not check this service if the pharmacy is only reconstituting a manufacturer's NON-STERILE product (e.g., reconstituting an antibiotic suspension) Pharmacy Hours of Operation (*check appropriate am/pm) Open Close Pharmacist-in-Charge VI License # Check here if PIC is licensed to practice in any other state or territory? List all other States/Territories By my signature, I acknowledge I am the pharmacist-in-charge of this pharmacy and attest that have read and understand the laws and rules related to this pharmacy. Print Name of Pharmacist-in-Charge Signature of Pharmacist-in-Charge Date Statement of Notary Public Subscribed and sworn before me this ______ day of ____________________ , 20 ______ Notary Public: _________________________________________ Seal Here My Commission Expires: ________________________________ Sunday am pm to am pm Monday am pm to am pm Tuesday am pm to am pm Wednesday am pm to am pm Thursday am pm to am pm Friday am pm to am pm Saturday am pm to am pm Staffing Pharmacists Name License # Name License # Certified Technicians Name License # Name License # THE OWNER OR ONE OF THE MANAGING OFFICERS MUST ANSWER THE FOLLOWING QUESTIONS: 1 Has the pharmacy or the corporation, partnership or other entity that owns the pharmacy been Yes No the subject of ANY professional disciplinary action or are any such actions pending against this entity by a regulatory authority? (e.g., surrender, revocation, reinstatement, suspension, fine, probation, restriction.) Include such Information for all states and territories, and for all regulated professions. Has the pharmacy or the corporation, partnership, or other entity that owns the pharmacy been 2 Yes No subject to court ordered probation as related to any offense? If you answered "YES" to question 1 and/or question2, include the name of the Board, licensing or 3 disciplinary authority, and the date of the order, and, if applicable, the date of the termination of the conditions and/or probation: 4 Does this pharmacy participate in the Medicaid Program? Yes No I hereby attest that the foregoing statements on this form or those on any attachment(s) to this form are to the best of my knowledge true and correct and that they are all given of my free will. I agree that any misstatement(s) or omission(s) as to material facts will constitute violation of and subject me to the penalties set forth in the Virgin Islands Pharmacy Act and Rules. I agree to comply with the Virgin Islands Pharmacy Act and Rules Print Name Owner/Managing Officer Signature of Owner/ Managing Officer Date THIS SIGNATURE MUST BE NOTARIZED Statement of Notary Public Subscribed and sworn before me this ______ day of ____________________, 20 _______ Seal Here Notary Public___________________________________________ My Commission Expires: _________________________________