Board of Pharmacy - Change Licensing Information Request Form

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Controlled Substance (CS)

Please provide us with any changed information so that we can make the corrections.
Please allow 10 business days for any changes.

This is for Individuals ONLY!
Businesses must call the Reno office at 1-800 364-2081

License Number:

*CS License #:

NAME: First Name Middle Last Name

Current Name: *First & Last
CHANGE Name: First & Last

PRACTICE NAME & ADDRESS:

REMEMBER: Anyone holding a controlled substance license (Practitioner) may not change to a home address.
A Nevada practicing address is REQUIRED. If you no longer practice in Nevada, you must notify our office by clicking HERE and e-mailing us that you have left the state of Nevada.

NEW PRACTICE NAME:

NEW PRACTICE Address:

City:

State:

NEVADA Zip

*Area Code *Phone #

FAX #

*E-Mail:

Provide any other information you think we need

*Required Field

Last Updated: 12/04/07 09:38:37 AM
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