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Pharmacy Health Care Entity License ApplicationPacketContents:1.690-256. Contents List/Mailing Information.1 page2.690-257. Application Instructions Checklist. 2 pages3.690-258. Health Care Entity License Application. 2 pages4.RCW/WAC and Online Web Site Links.1 pageIn order to process your request:Mail your application with initialdocumentation and your check ormoney order payable to:Send other documents not sentwith initial application to:Department of HealthPharmacy Quality AssurancePO Box 1099 Commission CredentialingOlympia, WA 98507-1099PO Box 47877Olympia, WA 98504-7877Contact us:360-236-4700DOH 690-256 June 2012
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Application Instructions ChecklistWhen your application for pharmacy health care entity license is received by theDepartment of Health, you will be notified in writing of any outstanding documentationneeded to complete the application process.Indicate type of application—New, change of ownership, change of location,or name change. New—First time requesting a pharmacy health care entity license. Change of Ownership—When name of legal owner/operator changes resultingfrom the sale of licensed health care entity. Change of Location—Include your current license number. Name Change Only—List your current facility name.FF Check One:Please check your legal owner/operator business structure type according to yourWashington State Master Business License.FF Application Fees: Check one; with controlled substance or without controlledsubstance. Fees are non-refundable. You can check the online fee page for currentfees.FF 1. Demographic Information:Uniform Business Identifier Number (UBI #): Enter your Washington State UBI#. All Washington State businesses must have UBI #’s. City, county, and stategovernment departments also have UBI#’s.Federal ID Number (FEIN #): Enter your Federal ID Number, if the business hasbeen issued one.Legal Owner/Operator Name: Enter the owner’s name as it appears on the UBI/Master Business License.Mailing Address: Enter the owner’s complete mailing address.Phone and Fax Numbers: Enter the owner’s phone and fax number.Email and Web Address: Enter the owner’s email and agency Web addresses, ifthey have them.Facility/Agency Name: Enter the agency’s name as advertised on signs,brochures or Web sites.Physical Address: Enter the agency’s physical street location including city, state,zip code, and county.Phone and Fax Numbers: Enter the agency’s phone and fax number.Mailing Address: Enter the agency’s mailing address, if different than physicaladdress.Email Address: Enter the agency’s email address, if available.DOH 690-257 June 2012Page 1 of 2
FF 2. Facility Information:Drug Enforcement Administration Registration Number: Enter the federal DEAregistration number if dispensing controlled substances. Enter “pending” if theHealth Care Entity has not been issued its DEA registration number.Pharmacist Consultant: Enter name of pharmacist, license number, and date ofappointment.FF 3. Contact Information:Enter name, title, phone number, fax number, and email address.FF 4. Additional Information:Corporation information: Enter date of incorporation, corporate number, andstate of corporation.Legal Owner: List the names, titles, addresses, and phone numbers of thecorporate officers, partners, members, and managers. Attach additional completedpages if you need more space.Change of Ownership Information: List the previous legal owner name, previousname of facility, previous health care entity license number, and effective date ofownership change.FF Signature:Signature of legal owner or authorized representative.Date signed.Print name of legal owner or authorized representative.Print title of legal owner or authorized representative.DOH 690-257 June 2012Page 2 of 2
DateStampHereFees (check all that apply) Without controlled substance. Fee With controlled substance. FeeAll application fees are nonrefundableYou can check the online fee page forcurrent fees.Revenue: 0262010000Pharmacy Health Care Entity License ApplicationThis is for: New Change of Ownership Change of Location—Current License # Name Change Only—Current Facility NameCheck Oneccc AssociationCorporationFederal Government AgencyLimited Liability CompanyLimited Liability Partnershipcccc Limited PartnershipMunicipality (City)Municipality (County)Non-Profit CorporationPartnershipccccSole ProprietorState Government AgencyTribal Government AgencyTrust1. Demographic InformationUBI #Federal Tax ID (FEIN) #Legal Owner/Operator NameMailing AddressCity State Zip CodeCountyPhone (enter 10 digit #) Fax (enter 10 digit #)Email Address Web Address:Facility/Agency Name (Business name as advertised on signs or web site)Physical AddressCity State Zip CodeCountyFacility Phone (enter 10 digit #) Fax (enter 10 digit #)Email AddressMailing Address (If different than physical address)City State Zip CodeCountyFor Office Use OnlyLicense # Issue DateDOH 690-258 June 2012Page 1 of 2
2. Facility InformationDrug Enforcement Administration (DEA) #Background QuestionsYes No1. Have any applicants, partners, or managers had a suspension, revocation, denial, or restrictionof a professional license?. If yes, list and explain on a separate sheet of paper.2. Have any applicants, partners, or managers been found guilty of a drug or controlledsubstance violation (including samples)?. If yes, list and explain on a separate sheet of paper.Pharmacist ConsultantLicense NumberDate of AppointmentName3. Contact InformationContact PersonNameTitlePhone (enter 10 digit #)Email Address4. Additional InformationDate of IncorporationCorporate NumberState of CorporationLegal Owner Information—attach additional completed pages if you need more space.List names, addresses, phone numbers, and titles of corporate officers, partners, members, and managers.NameAddressPhone (enter 10 digit #) TitleChange of Ownership InformationPrevious Name of Legal OwnerPrevious Name of FacilityPrevious Pharmacy License # Effective Date of Ownership ChangeSignatureI certify that I have received, read, understood, and agree to comply with state law and rule regulating thislicensing category. I also certify that the information herein submitted is true to the best of my knowledgeand belief.Signature of Owner/Authorized Representative DatePrint Name Print TitleDOH 690-258 June 2012Page 2 of 2
RCW/WAC and Online Web Site LinksRCW/WAC LinksUniform Disciplinary Act. RCW 18.130Administrative Procedure Act.RCW 34.05Administrative procedures and requirements. WAC 246-12Pharmacy Laws.RCW 18.64Pharmacy Rules. WAC 246-863Health Care Entity Rules. WAC 246-904On-LineAIDS Training Resources. Reference PagePharmacy Quality Assurance Commission. Web PageRCW/WAC and Online Web Site Links June 2012
When your application for pharmacy health care entity license is received by the Department of Health, you will be notified in writing of any outstanding documentation needed to complete the application process. Indicate type of application—New, change of ownership, change of location, or name change.File Size: 230KB
