:: Initial Applications ::

NON-RESIDENT INSTRUCTIONS

APPLICATION FEES ARE NONREFUNDABLE AND NONTRANSFERABLE :

A South Dakota nonresident pharmacy is defined in SDCL 36-11-19.2 as any pharmacy located outside this state that:
   (1) Ships, mails, or delivers any dispensed drug to a resident in this state pursuant to a legally issued prescription; and
   (2) Provides to a resident of this state information on drugs or devices including advice relating to therapeutic values, potential hazards, and uses; or
   (3) Counsels pharmacy patients residing in this state concerning adverse and therapeutic effects of drugs.

1. This “initial” nonresident pharmacy application should be used by a nonresident pharmacy that has never been issued a South Dakota license.
   a. If pharmacy was ever issued a South Dakota nonresident pharmacy license in the past, a “renewal” application should be completed NOT an “initial” application.

2. For nonresident “initial” application information:
   a. Please click on this link: SD Board of Pharmacy – application information
        i. For instructions
        ii. For required forms to print, complete, and upload

Pharmacist Notarized Affidavit form

Notarized Supplement to Application form

3. No license is required to ship the following in or within South Dakota:
a.Medical devices that do not contain a legend drug.
b.Over-the-counter drugs.

4. A pharmacist-in-charge (PIC) of a nonresident pharmacy is not required to have a South Dakota pharmacist license.

NEW APPLICATION

What type of application is this (select one):

Initial Application for a Nonresident (outside of South Dakota) Pharmacy

HOME STATE LICENSE/INSPECTION

Home State License

Home State

Home State License Number

Home State License Expiration

Home State license or equivalent document

Other states licensed in

Inspection

Must be less than 4 years old.
If not less than 4 years old OR no inspection available, upload a written explanation of why the inspection requirement cannot be met.

Type of Inspection:

Date of last inspection:

Explanation

Inspection document, if no inspection or inspection is over 4 years since an inspection, please upload a document stating reason why

Were there any deficiencies/corrections required based on inspection identified above including any 483 observations?

Yes

OWNERSHIP

Type of Ownership

EMPLOYEES

Staff Pharmacists

None

Registered Technicians currently working at this location

None

Pharmacist Interns currently working at this location

None

Full Listing of Pharmacists, Technicians, and Interns, if applicable

INITIAL REGULATORY QUESTIONS

Have you, or any other managing officer, director, owner, or member ever plead guilty, no contest, or received a suspended imposition of sentence for a felony or other criminal offense (excluding minor traffic violations)?

Yes

Has the pharmacy been disciplined in the last three (3) years by any state or federal agency?

Yes

APPLICATION INPUT PREVIEW

AFFIRM AND SUBMIT

I certify that the applicant will operate in a manner prescribed by federal and state laws and rules adopted by the Board. I declare and affirm under the penalty of perjury that this application has been examined by me, and to the best of my knowledge and belief, is in all things true and correct.

E-Signature

Date

License Fee

Debit /Credit

Card Type

Person’s Name on Card

Card #

Expiration Date (MM/YY)

Security code (3-digit number or 4-digit number if American Express/Amex)

All application fees are nonrefundable and nontransferable.

Name of Partnership

Address1

Address2

Address3

Zip

City

State

Phone Number

Name of Corporation

Address1

Address2

Address3

Zip

City

State

Phone Number

Name Of LLC

Address1

Address2

Address3

Zip

City

State

Phone Number

Staff Pharmacist License #

Staff Pharmacist Name

Staff Pharmacist Average Hours Worked/Week

Registered Technician Registration Number

Registered Technician Name

Registered Technician Average Hours Worked/Week

Pharmacist Intern Registration Number

Pharmacist Intern Name

Pharmacist Intern Average Hours Worked/Week

Monday	Tuesday	Wednesday	Thursday	Friday
Saturday	Sunday

INITIAL APPLICATION FOR NONRESIDENT (Out-of-State) PHARMACIES