Pharmacy Establishments

Resident In State Pharmacy

Change of Location

Instructions

1. Complete Endorsement Application (PH 202 32 KB)
2. Complete Pharmacy Information Form (PH 210 33 KB)
   • Part II (page 3) of this form requires a diagram of the establishment:
     1. Please indicate the size of the Compounding and Dispensing area and the Registered Area. Fill in the blank spaces.
     2. Indicate the placement of the sink and refrigerator in red ink.
     3. Outline the registered area in one color of highlighter and indicate the compounding and dispensing area in another color of highlight or red ink.
3. Check or Money Order for $50 payable to the New York State Education Department

In addition, submit the following:

• Lease or deed for the premises made out to the registered name of the corporation or LLC.
• Assignment of lease for the premises where applicable to the name of the corporation or LLC you are registering.
• Certificate of Occupancy for the premises.
•  Photographs: (Staple all photos to 8½ by 11 typing paper. Please do not send multiple photos of the same thing or same angle.)
  1. Photo of outside signs on the building. We must be able to read the signs.
  2. Photo of front exterior showing the registered name of the corporation or LLC on the exterior. We must be able to read the sign.
  3. If the pharmacy is a department. Include photos of the department with the gates open and closed.
     
• Final Prescription Label with registered name of the corporation of LLC and new address.

You will be notified by mail regarding the inspection at the new location.