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Board of Pharmacy

Mailing:
P.O. Box 625
Jefferson City, MO 65102

Overnight/Physical:
3605 MO Blvd.
Jefferson City, MO 65109

573.751.0091 Telephone
573.526.3464 Fax
800.735.2966 TTY
800.735.2466 Voice Relay
MissouriBOP@pr.mo.gov
http://pr.mo.gov/pharmacists

Pharmacist Disciplinary Action Report

Any entity that employs or contracts with a Missouri licensed pharmacist to provide health care services to individuals is required to report to the Board:

Any disciplinary action against a Missouri licensed pharmacist that would be cause for Board discipline under section 338.055, OR
The voluntary resignation of a Missouri licensed pharmacist against whom any complaints or reports have been made which might have led to disciplinary action.

[Section 383.133, RSMo].

Reports must be submitted to the Board within fifteen days of the disciplinary action. Complete the sections below to submit an electronic report (items with an asterisk are required by § 383.133, RSMo):

Provide the following information about the person making this report

Name of Person Making This Report: *

Street (line 1): *

Street (line 2):

City: *

State: *

Zip Code: *

Telephone # of Person Making this Report: *

E-Mail Address of Person Making This Report: *

Provide the following information about the subject of this report

Name of Pharmacist Who Is the Subject of This Report: *

Street (line 1): *

Street (line 2):

City: *

State: *

Zip Code: *

Telephone # of Pharmacists Who Is the Subject of This Report: *

E-Mail Address of Person Subject of This Report: *

Backgound Information

Date Discipline or Voluntary Resignation Occurred: *

Provide A Description of the Facts Which Gave Rise to the Issuance of the Report, Including, Dates of Occurrence.(Please include the pharmacy location at which the events occurred)

Are There Any Court Actions Pending Against the Subject of the Complaint Relating to the Incident Described in this Report (i.e.- pending criminal charges, malpractice lawsuits)?*

If Yes, List The Identity Of The Court, The Date Of Filing And Docket Number Of The Action. Respond 'unknown' if you do not have specific court information.

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Pharmacist Disciplinary Action Report