New Mexico Board of Pharmacy

Revision date: 12/2017

BOARD OF PHARMACY

New Mexico Regulation and Licensing Department

BOARDS AND COMMISSIONS DIVISION

5500 San Antonio Dr. NE ▪ Suite C ▪ Albuquerque, New Mexico 87109

(505) 222-9830 ▪ Fax (505) 222- 9845 ▪ (800) 565- 9102

www.RLD.state.nm.us/pharmacy.aspx

Non Resident Pharmacy Renewal Application

MAIL EARLY, PROCESSING TIME IS 5 TO 10 DAYS ONCE RECEIVED IN OUR OFFICE

License Number: ______________________ Location Address:

Name of Location: ______________________________ ________________________________

Address: _____________________________________ ________________________________

______________________________________ _______________________________

Fax No. ___________________________ Phone No. _______________________

Contact Person Name and Title: ____________________________________________________

Contact Person Telephone Number _________________________

Hours of operation:

Mon

Tue

Wed

Thu

Fri

Sat

Sun

Please attach a copy of your most recent board of pharmacy inspection report(s)

and a list of all pharmacy staff

Make sure staff list includes name/title/registration number (if applicable) with expiration date.

Fees: $400.00 Biennial

$100.00 Late Fee if renewal is not postmarked by December 31, submit the late penalty.

(Make check or money order payable to New Mexico Board of Pharmacy)

Any change of registered pharmacists or support personnel must be reported to the New Mexico Board of Pharmacy, in writing, within ten (10) days.

Any change of pharmacist-in-charge must be reported immediately.

I/we hereby understand the license expires December 31 of every other year, and the license is not transferable.

A separate license is necessary for each pharmacy location. This application must be received or postmarked by December 31

, if not I/we will send

the $100 late fee in addition to the $400 biennial fee.

I/we have not since the time of initial licensure or last renewal, been arrested, investigated for, charged with, convicted of, sentenced, entered a plea

of nolo contendere, or entered into any other legal agreements for any criminal offense in any state, territory or possession of the United States or by

the federal government.*

Signature__________________________________________________________________________________

I/we have not since the time of initial licensure or last renewal, had any disciplinary actions, nor are there any pending actions against me/the

pharmacy, and to my knowledge I/we have not been investigated by any professional licensing authority.*

Signature__________________________________________________________________________________

*Please explain any failure to sign the statements above.

Explain the circumstances, include a copy of the judgment, and attach to this application.

I (we) certify under penalty of perjury that the information given in this application is true and accurate to the best of my (our) knowledge.

__________________________ _____________________________________ __________________

Signature – Owner or Officer Print Name of Officer or Owner Date

__________________________ ___________________________________ _____________ ____________

Signature – Pharmacist-In-Charge Print name of Pharmacist-In-Charge License Number Date

Original Application, Self-Assessment and fees must accompany each other; otherwise processing time will be delayed.

Retain a copy of all information submitted and form of payment for future reference.



Please complete Non Resident Self-Assessment on the back of this application.



Revision date: 12/2017

BOARD OF PHARMACY

New Mexico Regulation and Licensing Department

BOARDS AND COMMISSIONS DIVISION

5500 San Antonio Dr. NE ▪ Suite C ▪ Albuquerque, New Mexico 87109

(505) 222-9830 ▪ Fax (505) 222- 9845 ▪ (800) 565- 9102

www.RLD.state.nm.us/pharmacy.aspx

Non-Resident Pharmacy Self-Assessment Form

The Pharmacist-In-Charge is responsible for completing this self-assessment form.

Please circle the correct answer. Return the completed form.

1. Has any State Licensing or Disciplinary Board or comparable body in the Armed Service, denied your application for

licensure, reinstatement or renewal, or taken any action against your license, including, but not limited to reprimand,

suspension, or revocation (license of Pharmacist-In-Charge and/or facility)? Y N

If yes, explain and attach a copy of the relevant document(s).

2. Do you dispense controlled substances to patients in New Mexico? Y N

A. If yes, do you have a current NM State Controlled Substance registration? Y N

License #: CS__________________ Expiration Date: _______________

3. Does your pharmacy compound preparations for NM residents? Y N

A. If yes, do you compound sterile preparations? Y N

a. Are you compliant with USP <797> requirements? Y N

b. Do you compound only patient specific medications? Y N

c. Are preparations only labeled for use on a specific patient? Y N

d. Do you distribute or cause to be distributed non-patient specific compounded product? Y** N

B. If yes, do you compound non-sterile preparations? Y N

a. Are you compliant with USP <795> requirements? Y N

b. Do you compound only patient specific medications? Y N

c. Are preparations only labeled for use on a specific patient? Y N

d. Do you distribute or cause to be distributed non-patient specific compounded product? Y** N

4. If your pharmacy compounds sterile preparations for NM residents, you must provide a copy of your most recent CSP

operations inspection report which demonstrates operation in conformance with the requirements of applicable USP/NF

General Chapters numbered below 1000. The inspection must have occurred within the 18 months immediately preceding

receipt of the license application by the board.

**A pharmacy cannot distribute or cause to be distributed into NM non-patient specific compounded product.

Compliance with NMAC 16.19.37 is required in order to distribute non-patient specific compounded sterile human drug

product into NM. If you answered Y to distributing into NM non-patient specific compounded product, you must attach

an explanation.

Attestation of truthful information provided and compliance with laws and regulations:

Producers of sterile preparation: The registrant/licensee is in compliance with USP <797> requirements, and only dispenses

medication pursuant to a valid prescription as defined in NMSA 61-11-2(CC). The registrant/licensee is in compliance with NM

Board of Pharmacy regulations, as applicable. I (we) attest under penalty of perjury that the information given on this form is true and

accurate.

SIGNATURE-PHARMACIST-IN-CHARGE [16 NMAC 19.6.9(A)(8)] DATE

PRINTED NAME-PHARMACIST-IN-CHARGE PHONE NUMBER & E-MAIL

I (we) do not produce sterile preparation(s). The registrant/licensee is in compliance with NM Board of Pharmacy regulations, as

applicable. I (we) attest under penalty of perjury that the information given on this form is true and accurate.

___________________________________________________________________________________________________________

SIGNATURE-PHARMACIST-IN-CHARGE DATE

PRINTED NAME-PHARMACIST-IN-CHARGE PHONE NUMBER & E-MAIL