:: Initial Applications ::

WHOLESALE AND OTHER DRUG DISTRIBUTORS AND 503B OUTSOURCING INSTRUCTIONS

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

Please review these items before proceeding:

DO NOT use this application for a Change of Ownership. Complete a wholesale & other drug distributor RENEWAL application.

DO NOT use this application if entity had a wholesale & other drug distributor license in the past. Complete a wholesale & other drug distributor RENEWAL application.

An entity must be licensed if a medical device contains a legend (prescription) drug.

South Dakota does not license out-of-state third party logistic providers (3PLs).

OWNERSHIP

REGISTERED AGENT IN SD

Name

Address1

Address2

Address3

Zip

City

State

County

For a list of SD registered agents go to https://sdsos.gov/docs/business/CRA_list.pdf

OWNER CERTIFICATION

Attachments – upload to this section the mandatory document, ‘Owner or Corporate Officer Certificate Form’. The Owner or Corporate Officer Certification Form must be signed with original ink or an e-signature will be accepted that is similar to E-Signature by Adobe Sign. If a power of attorney is being used, the power of attorney documents must be uploaded with the Owner or Corporate Officer Certificate Form.

Owner or Corporate Officer Certification Form

DISCIPLINARY ACTION

Have any misdemeanor or felony convictions or disciplinary actions (including pending) been taken against the applicant and/or licensed entity in the last 7 years?

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

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)

Name

Address1

Address2

Address3

Zip

City

State

Country

Copy of Agreement first page and signature page

Name of Business

Address1

Address2

Address3

Zip

City

State

Country

Copy of 3PL agreement, first page, along with signature page

3PL NABP Drug Distributor Accreditation (formerly VAWD) upload

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

Name

Address1

Address2

Address3

Zip

City

State

Phone Number

Wholesale Distributor	Manufacturing Distributor	Repackager	Distribution Center
Reverse Distributor	Virtual Manufacturing	Virtual Distributor	Private Label Distributor
503B Outsourcing Facility	In State Only - Third Party Logistics Provider	Other

Medical Gases	DEA Controlled substance	Ephedrine or pseudoephedrine products	Noncontrolled prescription drugs (‘federal legend’)
Over-the-Counter drugs	Veterinary prescription drugs	Other

Wholesale & Other Drug Distributors Initial / New Application