Maryland Board of Pharmacy
4201 Patterson Avenue
Baltimore MD 21215-2299
Phone: 410-764-4755
Fax: 410-358-6207
www.dhmh.maryland.gov/pharmacy

CHANGE OF INFORMATION FORM

Pharmacists, Pharmacy Technicians, and Pharmacy Interns should use this form to notify the Board of Pharmacy of any name, address, employment, telephone, and all pertinent informational changes. Name changes must include documentation such as, but not limited to, a copy of a marriage certificate, official court documents, etc.

Requests for a duplicate license before your renewal must be submitted with the correct fee payment:

Technicians and Interns fee: $10

Pharmacists fee: $30

Your check or money order must be made payable to The Maryland Board of Pharmacy.

Please check here if you are requesting a duplicate license: ☐

The Board requires this change of information to be reported in order to ensure that the licensee will continue to receive Board information. Failure to provide the Board with certain up-to-date and accurate information may constitute grounds for action under HO 12-313(b), (1), (6), (7) and/or (24), Annotated Code of Maryland.

PLEASE COMPLETE THE ENTIRE FORM

Effective Date of Change:	Click here to enter a date.
Licensee Name:	Click here to enter text.
License/Registration Number:	Click here to enter text.
Previous Name:	Click here to enter text.
Previous Address:	Click here to enter text.
Previous City, State, Zip:	Click here to enter text.
New Address:	Click here to enter text.
New City, State, Zip:	Click here to enter text.
Telephone #:	Click here to enter text.
Email Address:	Click here to enter text.

Employer Name:	Click here to enter text.
Employer Permit Number:	Click here to enter text.
Employer Address:	Click here to enter text.
Employer City, State, Zip:	Click here to enter text.
Employer County:	Click here to enter text.
Employer Telephone #:	Click here to enter text.

Mail, Fax or Email this form to: MARYLAND BOARD OF PHARMACY

P.O. BOX 2051, BALTIMORE, MD 21203-2051

Telephone: (410) 764-4755 Fax: (410) 358-6207

Email Address: DHMH.MDBOP@maryland.gov