Form 08-4150 - Pharmacy Self-Inspection Report - Alaska State Board Of Pharmacy
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8ALASKA STATE BOARD OF PHARMACY
PAGE 1 OF 8
PHARMACY SELF-INSPECTION REPORT
Official Name:
Check Where Applicable
DBA Name:
Initial Application
Renewal
Address:
Change in Ownership
Telephone Number:
Change in Location
Re-Inspection
Fax Number:
Hours:
Pharmacy License Number and
Expiration:
DEA Number and Expiration:
Check Where Applicable
Pharmacist-in-Charge and License
Retail
Number:
Other Pharmacist and License Number:
Institutional
Other Pharmacist and License Number:
Sterile RX Compounding
Other Pharmacist and License Number:
Other Pharmacist and License Number:
Other Pharmacist and License Number:
Other Pharmacist and License Number:
12 AAC 52.200(b)(1)
Pharmacist-in-charge
Other Pharmacist and License Number:
The responsibility of the
pharmacist-in-charge include
compliance with all laws and
regulations governing the
operation of the pharmacy.
NOTE* Keep a copy of this report on file.
08-4150 (Rev. 5/98)
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