Required Documents

All Pharmacies and Chains

1. A list of all states your pharmacy is licensed in including copies of each license

2. Name and copy of state license(s) of the current Pharmacist-In-Charge

3. Copy of pharmacist(s) license(s) in every state that requires it

4. Copy and list of Technician license(s)

5. Copy of state-issued Controlled Substance permit and Federal Pharmacy DEA license

6. Copy of your pharmacy’s professional liability insurance policy showing amount of coverage and expiration dates

7. Documentation disclosing ownership structure of applicant pharmacy and any past changes in ownership and any changes in pharmacy name

8. Copy of your most recent Office of the Inspector General (OIG) exclusion search for employees and owners

9. Provide documentation disclosing all associations with PSAOs, and Compounding Networks

10. Copy of your most recent Office of the Inspector General (OIG) exclusion search for employees and owners:  Visit the OIG website http://exclusions.oig.hhs.gov/ and do a search of the owners and employees.  You can search multiple individuals at one time.

11. FWA Training Log for employees

12. List of pharmacy’s drug wholesalers

13. Name of PSAO and buying groups

14. W-9 Information for pharmacy