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: