:: Initial Applications ::

South Dakota Board of Pharmacy

SD Pharmacies Initial / New Application

SOUTH DAKOTA PHARMACY INSTRUCTIONS

For application information, instructions, and forms to upload, please go to this link: https://doh.sd.gov/licensing-and-records/boards/pharmacy/licensing-requirements/pharmacies/

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

REGULATORY QUESTIONS

Has the pharmacist-in-charge, sole proprietor, any other managing officer, director, 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

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 of the person filling out this renewal (Type in full name)

Date

License Fee

Select Debit or 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.

Staff Pharmacist Home State License Number

Staff Pharmacist Name

Staff Pharmacist Average Hours Worked/Week

Registered Technician Registration Number

Registered Technician Name

Registered Technician Average Hours Worked/Week

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

Pharmacist Intern Registration Number

Pharmacist Intern Name

Pharmacist Intern Average Hours Worked/Week

Mailing Address: 4001 W Valhalla Blvd, Sioux Falls, SD 57106 Phone: (605) 362-2737

Retail	Independent	Hospital	Telepharmacy	Sterile Compounding
Non-Sterile Compounding	LTC	Uses Central Fill	Central Processor	Other

Monday	Tuesday	Wednesday	Thursday	Friday
Saturday	Sunday