Arkansas Department of Health

Name of Pharmacy:

Pharmacy Phone Number:

Pharmacy Email:

Pharmacy Address:

Address (Line 2):

City:

ST

Zip

Select State Alaska Alabama Arkansas American Samoa Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Guam Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Marshall Islands Michigan Minnesota Missouri Northern Mariana Islands Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Pohnpei Puerto Rico Palau Rhode Island South Carolina South Dakota Tennessee Texas US Minor Outlying Islands Utah Virginia U.S. Virgin Islands Vermont Washington Wisconsin West Virginia Wyoming

First Name of Pharmacist-in-Charge (PIC):

Last Name of Pharmacist-in-Charge:

PIC Phone Number:

PIC Email:

Person Submitting Application:

Title:

By checking this box, I attest that the above named pharmacy does not dispense controlled substances at a pharmacy located in Arkansas or as an out of state pharmacy mailing prescriptions to an Arkansas address. If the above named pharmacy shall begin to dispense controlled substances, they will notify the Arkansas Prescription Drug Monitoring Program to withdraw the waiver and begin to report dispensations.