:: Initial Applications ::

SD Pharmacies Initial / New Application

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/

License Classification

Legal Name of Business (must be the same as DEA title, if applicable)

Type of Practice – Check all that apply

Other States Licensed In

Other states licensed in

Pharmacist-in-Charge

Pharmacist-in-Charge South Dakota License Number

Pharmacist-in-Charge Name

Pharmacist-in-Charge Email

Pharmacist-in-Charge Phone Number

Notarized Affidavit affirming Pharmacist-in-Charge understands SD Pharmacy Laws/Rules and intends to abide by the SD Pharmacy Law/Rules.

Licensure Application Preparer Information

Is Pharmacist-in-Charge filling out this application?

Yes

Type of Ownership

Name and Address of Partnership

Name and Address of Corporation

Name and Address of LLC

Partner/member/officer Information

Is pharmacist-in charge 100% owner of the nonresident pharmacy?

Yes

Notarized Supplement to Application Affidavit

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

Reporting to the South Dakota Prescription Drug Monitoring Program (SD PDMP) is required per SDCL 34-20E and ARSD 20:51:32. However, a waiver/exemption from reporting to the SD PDMP can be requested. A waiver/exemption can be applied for if this pharmacy provides services for in-patient care only, never dispenses any controlled substances (Schedule II, III, IV-includes CV), or is a medical facility that dispenses an interim quantity on an outpatient emergency basis (not to exceed a 48 hour supply). If this pharmacy does not practice any of these exemption options, then this pharmacy MUST report to the South Dakota Prescription Drug Monitoring Program.

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

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)

All application fees are nonrefundable and nontransferable.

Staff Pharmacist Home State License Number

Registered Technician Registration Number

Pharmacist Intern Registration Number

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

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Saturday	Sunday