2017 Wisconsin Act 278, beginning August 1, 2018, prior to submitting an application for a credential, an individual may apply to the Department for a determination of whether the individual would be disqualified from obtaining the credential due to his or her conviction record. To apply for a predetermination, please fill out
Form #3085 and submit all required documentation specified on the form. Pursuant to
Wis. Stat. §
111.335(4)(e), the offenses or kinds of offenses that may result in a refusal, bar, or termination of licensure are published under Additional Resources on the left side of this page.
Pursuant to 2017 Wisconsin Act 319, beginning August 1, 2018, an applicant for an initial credential may apply for a reduction of the initial credential fee that is equal to 10% of the initial fee. Qualification is based on the federal adjusted gross income being at or below 180% of the federal poverty guideline prescribed for the applicant's family household size by the United States Department of Health and Human Services. To determine eligibility please visit the United States Department of Health and Human Services website at https://aspe.hhs.gov/poverty-guidelines, prior to submitting Form 3217.
Wis. Stat. § 440.08 (2), the required renewal date for the Pharmacy (In State) credential is 05/31/even years. Should you receive your initial credential in the months leading up to this date, you are still required to renew your license by the statutorily defined date.
The completed application with the fee and required documentation must be submitted at least 30 days prior to date the applicant wishes to open the pharmacy. Make sure to provide all information requested on the form:
- The location of the pharmacy
- A floor plan of the pharmacy.
Enclose one set of original floor plans, scaled to size, with a description of the various areas designated. Indicate location of sink and refrigerator. For specific floor plan requirements refer to Chapter Phar 6 of the Wis. Admin. Code.
- The name of the managing pharmacist.
- Every pharmacy shall be under the control of the managing pharmacist who is listed on Department records. The managing pharmacist shall be responsible for the professional operations of the pharmacy. A pharmacist may be the managing pharmacist of not more than one community and one institutional pharmacy at any time and shall be engaged in the practice of pharmacy at each location he or she supervises.
Self Inspection Report. This form must be completed and returned to the Department prior to opening.
To license a pharmacy where a change of ownership or change of location is involved, complete the steps above plus submit a Pharmacy Closing Affidavit completed and notarized by the former owner and forward it to the board office with the other required materials.
Register with the
Drug Enforcement Administration (DEA).
Application for Pharmacy (In State) Packet
609||Pharmacy License Application |
1301||Instructions to Applicants for Pharmacy Change of Ownership/Location Change /Original Licensure (This form is available to determine if licensure is required)|
|3217||Application for Fee Reduction (This form must accompany the application for the credential)|
|2552||Addendum to Application - Business Entities (this form is required for licensure)|
606||Pharmacy Closing Affidavit (this form is required to close a Pharmacy and must be submitted within ten days of closure)|
|1422||Pharmacy Self-Inspection Information Sheet |
|2550||Pharmacy Self-Inspection Report |
3085||Application for Predetermination|
2252||Convictions and Pending Charges|
3071||Fax Payment Form|
2556||Business Models and Requirements for Licensure (information regarding Out-of-State Pharmacy, Distributor, Manufacturer)|
2516||Change Managing Pharmacist Form (This form is required anytime a change in Managing Pharmacist occurs)|
2661||Change of Name, Ownership, Location or Address for Pharmacy, Wholesale Distributor or Manufacturer (Instructions and Information)|
2866||Pharmacy Remodel Request Form |
2634||Pharmacy Remodel Request Information Sheet (Instructions for filing Remodel Request Form #2866)|
2874||Remote Dispensing Site Notice (completed form must be submitted to the Board prior to operating remote site)|
Procedures for Reporting DEA Theft or Loss of Controlled Substances
|2691||Division of Enforcement Supplemental DEA Form for Reporting of Theft or Loss of Controlled Substances|
2821||Procedures for Reporting Theft or Loss of Controlled Substances (You will also need to contact the DEA and complete the DEA Form for Reporting a Theft or Loss of Controlled Substances.)|
2867||Pharmacy Variance Request Form and Information|
Pilot Program Forms
|Please click here for all Pilot Program Forms