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Name Change Form

The name of a current Louisiana licensee for distribution of legend drugs and legend devices may be changed if the name change is NOT the result of any changes in ownership. Changes in ownership of a licensee company/facility require submission of an application for new licensure as licenses are NOT transferable with regards to ownership changes.

  1. HAVE ALL REQUIRED DOCUMENTATION READY for upload, such as incorporation amendment or corporate resolution indicating the name change and the effective date for the name change, and (for out-of-state licensees) a copy of the home state license in the name.
  2. HAVE PAYMENT TOOLS AVAILABLE and ready, such as credit card or bank account information for e-check payments; processing charge of $25.
  3. ENTER THE LOUISIANA LICENSE NUMBER below for the name change. PLEASE CHECK NAME OF THE LICENSEE that is provided on the form
    that comes up to verify the correct Louisiana license number was provided.
  4. COMPLETE the name change request form.
  5. PRINT a copy of the completed name change form for your records BEFORE submitting the form.
License Number:


Verification Form

Request for License Verification:

Requests for verification of Louisiana license must be made in writing by providing the verification form provided by the state requesting the verification, providing the contact name and mailing address to return the completed verification to, and submission of the license verification fee or $15 (per LAC 46:XXXIV.801.A.6) for each verification requested.

  1. HAVE ALL REQUIRED DOCUMENTATION READY for upload.
    1. If the state requiring the license verification has a standard license verification form, complete portion of form for licensee and sign if applicable; then scan for upload submission.
  2. HAVE PAYMENT TOOLS AVAILABLE and ready, such as credit card or bank account information for e-check payments; $15 license verification fee required.
  3. ENTER THE LOUISIANA LICENSE NUMBER below for the verification. PLEASE CHECK NAME OF THE LICENSEE that is provided on the form that comes up to verify the correct Louisiana license number was provided. No fee refunds for incorrect submissions.
  4. COMPLETE the license verification request form.
  5. PRINT a copy of the completed license verification change form for your records BEFORE submitting the form.

To submit a request for license verification electronically with electronic fee payment by credit card or echeck enter the license number below and click “Next”. Please have the verification form ready to upload as well as your payment method available.

License Number:


License Change Form

Changes of information for a current Louisiana drug/device distributor license, such as changes to the facility and regulatory contact personnel, designated responsible party (DRP), revised lists of officers/directors or other states where licensure held, a copy of current valid home state license, or mailing address, should be submitted within 60 days after such changes become effective, per Board regulation./

NOTE: Changes to physical distribution address or business address (when a 3PLP is used for physical distribution and does not change) cannot BE CHANGED WITH THIS FORM. Louisiana licenses are NOT transferable with regards to location changes; applications for new licensure for the new distribution location are required.

1. PLEASE HAVE ALL REQUIRED DOCUMENTS READY for upload, when applicable, such as the completed DRP qualifications review form (for change of DRP), revised officers/directors list, new list of other states where licensure is held, and/or copy of current valid home state license (out-of-state licenses).
Designated Responsible Party Qualification Review Form
Note: Change of DRP for licensees physically located in Louisiana ONLY requires criminal history records (background) check, Criminal history records check documents must be submitted to the Board office via USPS/carrier including: Board Authorization form, LA State Police Disclosure form, Fingerprint Card (obtained from local law enforcement agency), and fee payment of $39.25 payable to LA Dept. of Public Safety.
2. ENTER below the Louisiana license number for the change in license information request. PLEASE CHECK THE LICENSE NAME provided on the form that comes up to verify the correct Louisiana license number was provided.
3. COMPLETE the information change request form.
4. PRINT a copy of the completed information form for your records BEFORE submitting the form.

License Number:


Online License Renewal Test

In order to process your renewal you must provide us with your License number and PIN.
Please be sure to enter your license/registration number as it appears on your renewal notice.

Annual License Renewal Period Starts October 1st and ends December 31st annually.
Please contact our office for late renewal information.

License Number:

PIN (Case Sensitive):

Request a new PIN (please use the email address associated with your regulatory contact)