Form Ph 210 PDF Details

In the realm of pharmacy operations within New York State, the Pharmacy Information Form PH210 issued by The University of the State of New York The State Education Department Office of the Professions State Board of Pharmacy provides a comprehensive framework for managing various pharmacy administrative requirements. This detailed form, available on the Board's website, guides applicants through the process of registering as either a full pharmacy store or as a department within a larger establishment. Applicants are required to provide extensive information including owner or corporation name, trade name, pharmacy address, and specifics regarding the nature of the pharmacy's operations. Additional facets of the form address the logistical considerations crucial to pharmacy management, such as renovations, changes in location, and day-to-day operational details. Furthermore, the form delves into practical aspects, such as the necessity of having appropriate facilities for drug storage, including a sink with hot and cold running water in the compounding area, a dedicated refrigerator, and adequate security measures. The importance of having a pharmacist on duty to oversee the procurement, storage, and dispensation of drugs is underscored, aligning with state regulations that ensure the safety and integrity of the pharmacy's services. As a pivotal document, the PH210 form embodies the regulatory commitment to maintaining high standards within the pharmaceutical profession, ensuring that each establishment is adequately equipped and managed to serve the public effectively.

QuestionAnswer
Form NameForm Ph 210
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesnew york form pharmacy, ny 210 information form, form pharmacy search, ny 210 information

Form Preview Example

The University of the State of New York

The State Education Department

Office of the Professions

State Board of Pharmacy

www.op.nysed.gov/prof/pharm/

PH210

Pharmacy Information Form

Instructions: Complete this form and submit it to the New York State Board of Pharmacy

Registration Number

 

 

 

 

to the address at the end of the form. Print in ink or type legibly.

 

 

 

 

 

 

 

 

 

Part I

 

 

 

 

 

 

 

Check what you are applying for (check one):

 

Registration as a FULL STORE

 

Registration as a DEPARTMENT

1.Name of owner/corporation under which registration has

been issued or is sought. Enter the name exactly as it appears on your Certificate of Inc. or Articles of LLC.

2. Trade Name

3. Pharmacy Address Line 1

Line 2

Line 3

City

State

County

ZIP Code

4.Complete ONE of the following

A.

B.

C.

D.

New Pharmacy

Proposed date of opening

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo.

 

day

 

 

yr.

 

Transfer of Ownership

Proposed date of transfer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo.

 

day

 

 

yr.

 

Name of previous registrant

 

 

 

 

 

 

 

Registration Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Change of Location

 

 

 

 

 

 

 

 

 

Date of change

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo. day

yr.

 

 

 

 

Previous Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Renovation

Date of renovation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

mo. day

 

yr.

 

 

 

 

Type of Renovation (check one)

Full store registration to Pharmacy Department.

Pharmacy Department to Full store registration.

Renovation of registered area.

Increase of registered square footage.

Decrease of registered square footage.

Hospitals only - Addition of new satellite area within facility.

Other

Pharmacy Form PH210, Page 1 of 4, Rev. 8/20

5.Pharmacy Description: Provide a brief detailed explanation of expected day to day pharmacy operations for this establishment.

6.

Do you have:

 

 

 

 

 

 

A. A sink with hot & cold running water in the compounding and dispensing area?

 

Yes

 

No

 

 

 

 

B. A separate refrigerator for storing the drugs?

 

Yes

 

No

 

 

 

 

C.

Basement storage?

 

Yes

 

No

 

 

 

 

D.

A security system?

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

7.

Daily schedule of hours that pharmacy will be opened (list days and hours)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Include a photo of front exterior showing CORPORATE NAME ON EXTERIOR OF BUILDING.

8. Pharmacy as a Separate Department: When a pharmacy is operated as a department of a larger commercial establishment, the area comprising the pharmacy shall be physically separated from the rest of the establishment, so that access to the pharmacy and drugs is not available when a pharmacist is not on duty. Identification of the area within the pharmacy by use of the words "drugs, medicines, drug stores, or pharmacy" or similar terms shall be restricted to the area licensed by the department as a pharmacy. ALL PHARMACIES MUST HAVE A MINIMUM OF 300 SQUARE FEET.

Will the pharmacy operate as a separate department within a larger non-registered general merchandising

 

Yes

 

No

establishment?

 

 

 

 

 

 

If yes: Name of the larger non-pharmacy business

 

 

 

 

 

 

 

 

 

 

Daily schedule of business activities (days & hours)

 

 

 

 

 

 

 

 

 

 

 

 

Attach the following:

 

 

 

 

 

 

 

Floor plan of general merchandising establishment showing location of pharmacy as closely to scale as possible. Highlight

 

the pharmacy department.

 

 

 

 

 

 

 

Photo of exterior of general merchandising establishment.

 

 

 

 

Photo of pharmacy department

- gate open.

 

 

 

 

Photo of pharmacy department

- gate closed.

 

 

 

 

Photo of exterior sign indicating pharmacy department hours if different from general merchandising area.

 

 

 

9.For completion of Part II:

Draw to scale the proposed pharmacy, indicating all dimensions. Show all doors and walls.

Indicate areas for storage of drugs (drug bays).

In red pen indicate R for refrigerator.

In red pen indicate S for sink that is located in the compounding and dispensing area.

In red pen indicate B for bathroom or explain location.

Outline the registered area in yellow.

Outline the compounding and dispensing area in another color.

Indicate the premises adjacent to the buildings, offices and public thoroughfares.

Name the adjacent businesses.

DO NOT SEND A BLUEPRINT, IT WILL BE DISCARDED.

Pharmacy Form PH210, Page 2 of 4, Rev. 8/20

Part II

1.

Compounding and dispensing area

 

sq. ft.

3. Indicate Scale

sq. ft.

2.

Total registered pharmacy area

 

 

 

 

 

 

 

sq. ft.

 

 

 

 

 

 

 

 

 

 

 

 

Pharmacy Form PH210, Page 3 of 4, Rev. 8/20

Part III

Attestation

I affirm that all information submitted to the Board of Pharmacy is true. I am familiar with the Pharmacy Handbook and the laws which govern pharmacy in New York State. I understand that pursuant to Education Law 6808(2)(e) "Every owner of a pharmacy is responsible for the strength, quality, purity and the labeling thereof of all drugs, toxic substances, devices and cosmetics, dispensed or sold, subject to the guaranty provision of this article and the public health law. Every owner of a pharmacy or every pharmacist in charge of a pharmacy shall be responsible for the proper conduct of this pharmacy. Every pharmacy shall be under the immediate supervision and management of a licensed pharmacist at all hours when open." No supervising pharmacist shall be listed as supervising pharmacist at more than one registered pharmacy at the same time.

Signature of applicant (Individual Owner, Partner, Corporate Officer, Member or *Other Authorized Person

Date

Print Name

Title

*Power of Attorney must be submitted

Part IV

Contact person to clarify information provided on this application

Name

Telephone

 

Fax

 

 

 

Email

To assure prompt filing, please be sure you have completed all portions of this APPLICATION and send it to:

New York State Education Department

Board of Pharmacy

89 Washington Avenue

2nd Floor West

Albany, NY 12234-1000

Pharmacy Form PH210, Page 4 of 4, Rev. 8/20

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Stage # 1 in completing new york ph 210

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Pharmacy Form PH Page  of  Rev, Hospitals only  Addition of new, and Other of new york ph 210

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