Free 01588.FH11 - Indiana

RECORD OF STORE CLOSING
State Form 1588 (R4 / 2-06)

INDIANA BOARD OF PHARMACY PROFESSIONAL LICENSING AGENCY 402 West Washington Street, Room W072 Indianapolis, Indiana 46204 Telephone: (317) 234-2067 www.pla.IN.gov

NOTICE:

Notify the Board not less than twenty (20) days before the transfer of controlled substances by completing section 1 and 2 and mailing this form to the Board. To properly transfer controlled substances, permission should be sought from the Federal Drug Enforcement Administration.

INSTRUCTIONS: The following steps need to be followed to properly close a pharmacy: 1. Destruction of controlled substances will occur in the presence of the Indiana Board of Pharmacy Inspector at the time of the closing inspection. All drugs to be destroyed (including quantities) must be listed on the proper form prior to the inspection. Schedule II's must be accurately counted; Schedule III's, IV's and V's may be estimated if they are in bottles of 1000 or less. The federal form which is required for destruction may be obtained through the Board's office. All drugs to be destroyed must be listed on the proper form prior to the inspection. Before submitting the licensed premises to an inspection all legend and controlled drugs (with the exception of those that the inspector will destroy), must be removed from the premises. Remove from inside and outside the licensed area all symbols and signs using the word "drugs", "drugstore", "prescriptions","pharmacy", "pharmacy department","apothecary", "apothecary shop", or any combination of such titles. This must be done before the closing inspection. At the time of the inspection the Indiana Board of Pharmacy Permit and State Controlled Substances Registration Certificate must be surrendered to the inspector. If these items are not locatable, an affidavit attesting to the loss of them must be completed and this affidavit will be turned over to the inspector. The final inventory of controlled substances will be reviewed by the Board's representative at the time of the inspection. The federal DEA certificate, unused order forms, and final inventory will be forwarded by the holder to the Federal Drug Enforcement Administration. SECTION I
Name of pharmacy Address (number and street, city, state, and ZIP code) Name of owner Name of pharmacist / manager Proposed date of closing (month, day, year) Permit number

2. 3. 4.

5. 6.

SECTION II
Proposed date for transfer of controlled substances (month, day, year) Name of pharmacy receiving controlled substances Address (number and street, city, state, and ZIP code) Federal registration number of pharmacy / entity receiving controlled substances: Controlled substances to be transferred Yes No

SECTION III
Removal of legend drugs Yes Name of pharmacy Address (number and street, city, state, and ZIP code) No

SECTION IV
Signature of owner Signature of pharmacy / manager or designee Signature of Indiana Board of Pharmacy inspector Comments: Date signed (month, day, year) Date signed (month, day, year) Date signed (month, day, year)

DISTRIBUTION: White - Agency; Canary - Store file; Pink - Owner / Manager