Change Licensing Information Form 

 
 

PHARMACIST OR TECHNICIANS (PT)        

 
 

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

This form is for Individuals Only!  Business must call the Reno Office at 1-800-364-2081.  

 

License Information (Required Information)

 
   Pharmacist License # 
   
Pharmacist Technician License #
   
 

Personal Information

 
Current Name:  *First
      
  Middle
    Last
Change Name to:      
   
 

New Personal Contact Information

 
Home Address:   City: State:    Zip:    
 Home Phone #:   
 Home Fax #:    
  Email Address:  
     
 

Business Contact Information

 
  Store # / Name:
Store Address:   City:   State:   Zip: 
   
Provide any other information you think we need: