Pharmacy (Out of State) - Forms

Please disregard the page in the application packet about ordering the code book from us for $5.28. Code books are no longer available through this Department. They can be viewed online or purchased through Document Sales.

Petitions for refunds must be in writing and may be granted only if the criteria set forth in Wis. Admin. Code s. RL 4.06 are met.

 

Out of State Pharmacy Application Forms

(all forms listed under this section are required for licensure)

Instruction Sheet for Out of State Application Form # 2736

Application for Out of State Pharmacy Form #2737

Addendum to Application -Business Entities Employer Identification Number Form # 2552 (This form is required with application form #2737. An applicaiton will not be complete without this form.)

Other Pharmacy Forms and Information

Pharmacy, Distributor or Manufacturer Change of Ownership Form #2661 (If licensure is required, must complete the Application Packet for Out of State Pharmacy.)

Change Managing Pharmacist Form # 2516

 

Other Forms and Information

Business Models and Requirements for Licensure Form # 2556
(Information regarding Out-of-state Pharmacy, Distributor, Manufacturer)