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TEXAS STATE BOARD OF PHARMACY 333 Guadalupe Street, Ste. 3-600 * Box 21 * Austin, Texas 78701 512-305-8021 * 512-305-8082 (fax) * www.tsbp.state.tx.us CORPORATION OWNERSHIP INFORMATION Please type or print clearly (ALL blanks must be completed. If not applicable, enter N/A.) NAME OF PHARMACY PHYSICAL ADDRESS OF PHARMACY (Street, City, State, Zip) vilorteigs (cid:9) tiez. 414 (cid:9) ei sic 13 (cid:9) p,i1,20,1x LIP(cid:9) ton,-1-_ - T / ) c. a4/ %I 5 i3ocKfiee- 7 5 .0.-7 MAILING ADDRESS OF PHARMACY (If different from physical) ATTENTION TO: (Person, Department, Etc) NAME OF CORPORATION OR LLC ATTENTION TO: ADDRESS OF CORPORATION OR LLC (Street, City, State, Zip) FEDERAL EMPLOYER ID NUMBER (see www.IRS.gov ) TELEPHONE NUMBER (for Corp or LLC) q1-1- 31f 3(2 g 32 q 7 02- 7 03- & (cid:9) .:9--7 NAME AND ADDRESS OF MALPRACTICE INSURANCE CARRIER (Provide statement if the Business will be Self-Insured) enlir GroJP 1-1-C (cid:9) 49 t1u45of) 51- (cid:9) 17' F 1. (cid:9) 10e--) York , NY (cid:9) /0013 CORPORATE OFFICERS/DIRECTORS (Top 4 of each.) NOTE! The person signing the pharmacy application and ownership form must be listed below. * Disclosure ofyour social security number (or federal employer identification number, ifyou are a partnership) is mandatory under Tex. Fam. Code Ann. §231.302 (Vernon 1999). The SSW is provided to identify persons relative to enforcement of child support payments. NAME (cid:9) n TITLE n 5 \r\e“ \t (cid:9) ltiv 5c P(cid:9) -D ttC,f0Nr HOME ADDRESS (city, state, and ZIP) ► ()Z 7 Pt( 0 ( (cid:9) C-cee 4( D( (cid:9) ffiesao t'.k.-t. 4 T )( (cid:9) -751 81 HOME PHONE NUMBER SOCIAL SECURITY NUMBER* DATE OF BIRTH(cid:9) TX PHARMACIST LICENSE # (if applicable) 5 M• el' $0- Providing Address of Record Indicates You Wish the Address and Home Telephone Listed Above Maintained Confidential ADDRESS OF RECORD ALTERNATE PHONE NUMBER (cid:9) a ( ) 703 -0 S (cid:9) 7 8 -Tay 1 N. fee. K —0( 2 iy ) g 0 zua/5 / 8 CITY(cid:9) .,-,rn STATE 1 ixe 59 Dii-f, 1 -e.c a 5 TITLE NAME (cid:9)(cid:9)(cid:9) TEXAS STATE BOARD OF PHARMACY 333 Guadalupe Street, Suite 3-600 Austin, Texas 78701 512-305-8000 * www.pharmacy.texas.gov Clinic Pharmacy (Class D) License Application Pharmacy Name & Location Address (Street, City, ZIP) FOR TSBP USE ONLY W 0 Men S (cid:9) HeCt Prk 00 f (cid:9) CR v N-.-)Vt Nt License No. Amount Receipt No. Applicant No. .D-Ci k LI (cid:9) 5 (cid:9) —6 uck4n-e-c 'Bluoi (cid:9) •ske 6 n 0 cx 1 t cx 5 (cid:9) 7'A (cid:9) 1 5 (cid:9) - - -----7 5 (cid:9) I Check here if for a NEW PHARMACY — n Check here if a CHANGE OF OWNERSHIP. I Pharmacy Telephone Number: if change of ownership, indicate previous name, P•114) (cid:9) P.77 5- 525 Lo address and license number of pharmacy: Pharmacy Fax Number : (2 I LI) ---75.52%4 Web Address: Email Address: Type of Ownership (check one) 6 I Application Fee Payable to Texas State Board of Pharmacy $454 n n Pharmacy License (cid:9) Corporation (cid:9) Limited Liability Company (LLC) n # of Pharmacy Balances/Scales (cid:9) .''--- (cid:9) x $25.00 (cid:9) $ Government (cid:9) • Partnership - n individual (cid:9) III (cid:9) Other (specify) TOTAL DUE(cid:9) $4161-1 Type of Pharmacy (check one) 7 Description of Services - Check All That Apply n n Alternative Visitation Schedule (cid:9) Other (specify below): n VPublic Health Expanded Formulary n Other (specify) q Home Delivery Pharmacist-in-Charge (cid:9) License # 1 1 Antic' • a ed Date of 0 . enin • and Hours of 0 , eration: •fflwrgi 111,MSSIIIIIMM1111107A(cid:9) 7 / / (cid:9) ,)-L)/6/. (cid:9) 5 - S (cid:9) ,,,-- t- (Pnnt or type) -, 2,I By my signature, I acknowledge I am the pharmacist-in-charge of this 12 Staff Pharnacist(s) (cid:9) License # pharmacy and attest that I have read and understand the laws and rules relating to this class of pharmacy. THIS SIGNATURE MUST BE NOTARIZED 1Y1(cid:9) V117) (cid:9) 0 du' 0 Signature of Pharmacist-in-Charge (cid:9) Date I 13 Registered Technician(s) (cid:9) Registration # E Subscribed and sworn to before me this (cid:9) .-C-7.- t ''"--- day of (cid:9) --3-4., itia-- (cid:9) , 20 (cid:9) 1 L Zst1-..7.;( ,„(cid:9) EDWIN ALLAN HERNANDEZ :4...,,4--V's Notary Public, State of Texa:-. -2 - i\ .: • (cid:9) My Commission Ex;, -: - ' ;;;;; **, (cid:9) Fe inumy$n_ . '; (cid:9)4. ; (cid:9) ' Notary Public (cid:9) 1 or 2 LIC-Class_D (Rev. 09/15) NOTICE: A Class D pharmacy license shall not be issued to a physician's office. Texas State Board of Pharmacy Rules define Clinic Pharmacy (Class D) as a facility/location other than a physician's office, where limited types of dangerous drugs or devices restricted to those listed in and approved for the clinic's formulary are stored, administered, provided, or dispensed to outpatients. (e.g. planned parenthood, public health). Read Rule 291.93. 14 Class D Clinic Pharmacy ip, (cid:9) n .-1 (cid:9) Al 1-.\ t) (a) Name and Texas License Number of Medical Director: (cid:9) t --, (cid:9) ',,--111cA-C-C,A (cid:9) 4 c4 ct .11 l () (cid:9) — = ) -7 (cid:9) ) --) (b) Attach a copy of the Pharmacy's Policy and Procedure Manual, which must include the clinic drug formulary if requesting permission to maintain an expanded formulary or an alternative visitation schedule, see Board Rule 291.93. 151 PRIMARY OWNER OR ONE OF THE MANAGING OFFICERS MUST ANSWER THE FOLLOWING QUESTIONS: n n (cid:9) 1. Has the pharmacy, or the corporation, partnership, or other entity that owns the pharmacy, been the subject of any professional (cid:9) YES* (cid:9) NO disciplinary action or are any such actions pending against this entity by a regulatory authority? (Examples: surrender, revocation, reinstatement, suspension, fine, probation, restriction). Include such information for all states, including Texas, and for all regulated professions. *If you answered "yes" to Question #1, include the name of the Board, licensing or disciplinary authority and the date of the Order, and, if applicable, the date of the termination of the condition and/or probation. 2. Has the (cid:9)pharmacy, or (cid:9)the (cid:9)corporation, partnership, (cid:9)or (cid:9)other entity (cid:9)that (cid:9)owns (cid:9)the (cid:9)pharmacy, (cid:9)been (cid:9)subject (cid:9)to court ordered probation • YES (cid:9) Er/NO as related to any offense? n (cid:9) 3. Are the customer service areas of the Pharmacy accessible to disabled persons, as defined by federal law? (cid:9) RYES (cid:9) NO 4. Does the pharmacy provide translating services for customers, including translating services for a person with impairment of hearing? (cid:9) If (cid:9)yes, what (cid:9)type (cid:9)of (cid:9)ntra (cid:9)nslating (cid:9)services (cid:9)does the (cid:9)pharmacy provide? (check all (cid:9)that apnply (cid:9)): (cid:9) R/YES (cid:9) n (cid:9) NO Enr (cid:9) 1 (cid:9) Spanish (cid:9) n (cid:9) 3 (cid:9) Telecommunication Device for the Deaf (TDD) (cid:9) n (cid:9) 5 (cid:9) AT&T Translating Service 2 (cid:9) Vietnamese (cid:9) 4 (cid:9) American Sign Language (cid:9) 6 (cid:9) Other (cid:9) n (cid:9) 5. Does this pharmacy participate in the Texas Medicaid program? (cid:9) 13/YES (cid:9) NO n 6. Does this pharmacy participate in the Texas State Kids Insurance Program (SKIP)? (cid:9) YES (cid:9) a40 ATTEST: I hereby attest that the foregoing statements, on this form or those on any attachment(s) to this form are to the best of my knowledge true and 16 correct and that they are all given of my free will. I agree that any misstatement(s) or omission(s) as to material facts will constitute violation of and subject me to the penalties set forth in the Texas Pharmacy Act. I agree to comply with the Texas Pharmacy Act and Rules. THIS SIGNATURE MUST BE NOTARIZED: Subscribed and sworn to before me this (cid:9) day Signature of Owner / Managing Officer (cid:9) Date (cid:9) of (cid:9) , 20 Owner / Managing Officer's Name (Type or Print) (cid:9) Notary Public (cid:9) LIC-Class_D Rev.09/1 5) 2 of 2 TEXAS STATE BOARD OF PHARMACY 333 Guadalupe Street, Ste. 3-600 Austin, Texas 78701 512-305.8021(voice) 512-305-8075 (fax) www.pharmacy.texas.gov Corporation/Corporate Ownership Form Type or print clearly. Complete each and every blank. If not applicable, enter N/A DBA NAME OF PHARMACY (as listed on license application) (cid:9) NAME OF CORPORATION (owner of pharmacy) __ (cid:9) WOMEN'S HEALTH CARE CENTER, INC (cid:9) SHERRY TENISON f PHARMACY LOCATION ADDRESS (must match pharmacy application) MAILING ADDRESS OF CORPORATION (owner of pharmacy) STREET ADDRESS (cid:9) SUITE/UNIT # (cid:9) STREET ADDRESS (cid:9) I SUITE/UNIT # 2914 S BUCKNER BLVD(cid:9) B (cid:9) 1208 TAYLOR CREEK DR (cid:9) N/A (cid:9) I CITY (cid:9) i STATE (cid:9) ZIP (cid:9) CITY STATE ZIP (cid:9) DALLAS (cid:9) TX 75227 MESQUITE TX (cid:9) 75181 DESIGNATED PERSON OF CONTACT FOR PHARMACY authorized By Owner/Officer to Discuss Application Materials with TSBP Staff) (cid:9) DESIGNATED PERSON OF CONTACT FOR CORPORATION (cid:9) FULL NAME & TITLE: (cid:9) Phone: (cid:9) FULL NAME & TITLE: Phone: Email: (cid:9) Email: PHARMACY MAILING ADDRESS (If different than location address) (cid:9) I FEDERAL TAX INFORMATION FEDERAL EMPLOYER ID # — _STREET ADDRESS _ 1 SUITE/UNIT # (cid:9) 94-3432832 (cid:9) I (Required see wwwiRS.gov ) ; NAME & ADDRESS OF MALPRACTICE INSURANCE CARRIER N/A(cid:9) (cid:9) (Required)* CITY (cid:9) STATE(cid:9) ZIP CNA,E3,.F GROUP INC 99 HUDSON ST 12FL NEW Y , VozK i y jr013 if self-insured, provide a written statement ATTEST: I hereby attest that the foregoing statements or those on any attachment(s) to this form are to the best of my knowledge true and correct and that they are all given of my free will. I agree that any misstatement(s) or omission(s) as to material facts will constitute violation of and subject me to the penalties set forth in the Texas Pharmacy Act. I agree to comply with the Texas Pharmacy Act and Rules. THIS SIGNATURE MUST BE NOTARIZED: Ito- 4.4 LL nature o wner I Managing Officer Date SA j A41 .-‘,/t- Owner I Managing Officer's Name (Type or Print) t LIZ) Subscribed and sworn to before me this ip day of So0 4.,e(1121/% (cid:9) ,20 Notary Public nf (cid:9) CUSTOMER USE ONLY 1 1 111 1111 1 11111 1 1 FROM: (PLEASE PRINT) (cid:9) PHONE (cid:9) 1. (cid:9) (l)"1" S A ;4 - OC) 3 ItS/ EL 414579458 US 67°4 (A)41 (cid:9) e--1 v-1 d (cid:9) 7(cid:9) s--6 1 ' O`e. \,-n 1 JAM, PRIORITY V. (UNITED STATES * MAIL * POSTAL SERVICE ® EXPRESSTM PAYMENT BY ACCOUNT (if applicable) USPS° Corporate Acct. No. (cid:9) Federal Agency Acct.' No or Postal Service' Acct, DELIVERY OPTIONS (Customer Use Only) ORV3IN (POSTAL SERVICE USE ONLY), _ q SIGNATURE REQUIRED Note: The mailer must check the "Signature Required" box if the mailer: 1) al-Day (cid:9) q 2 Day q Matary (cid:9) t:JDPO Requires the addressee's signature; OR 2) Purchases additional insurance; OR 3) Purchases COD service; OR 4) Purchases Return Receipt service. If the box is not checked, the Postal Service will leave the item in the addreSsee's PO ZIP de Scheduled ellvery Date Postage mail receptacle. or otheraecure location without attempting to obtain the addressee's signature on delivery. (MM/DDNY Delq iverNyo O Spatt iuordnasy , Delivery (delivered next business day) otg /G $ c)-01--cic q Sunday/Holiday Delivery Required (additional lee, where available') .w q '1R0e:3fe0rA toM Delivery Required (additional fee, where available') Scheduled Dallier Insurance Fee COD Fee TO: (PLEASEPRUINSTP)S -. co(cid:9)m• or. •l (cid:9)ocal Post Office' for av0ail,a7bril7ity+. (cid:9) -3°.•Sn '0)-1 - (cid:9) • q q 1102: N30O AOMN 3:00 PM $ ret(cd• Skile4' PH4ONE6 pi,,, 1010 AM Delivery Fee Return Receipt Fee Live Animal i (cid:9) &4, (cid:9) -, (cid:9) c,/ 6 M Transportation Fee- -33 (cid:9) 33 (cid:9) LA AdrtA (cid:9) e. 3- a Weight (cid:9) at Rate $Su nday/Hollday Premium Fee $To tal Postage & Fees $ Pr $ tiL /-1 7) (cid:9) Y-7 (7/964 Accept- (cid:9) e Initials $ DELIVERY (POSTAL SERVICE UCc. ZIP + 4t (U.S, ADDRESSES ONLY) Delivery Attempt (MM/DD/YY) Time Employee S gnature q AM 0 PM n For pickup or USPS Tracking", visit USPS.com or call 800-222-1811. Delivery Attempt (MM/DCWY) Time Employee SIgnatwo n $100.00 insurance included. q AM 0 PM LABEL 11—-B, S E. PTEMBER 2015 PSN 7690-02-000-9996 2-CUSTOMER COPY USTOMER USE ONLY VI :TROeM: n(PLE AS;E5 PRIN0T) (cid:9) PHONE „.1 5505 toceotuickY EL 526585864 US - GortEnti 1:6i. I x -7 ODLt5 a PRIORITY UNITED STATES * MAIL * POSTAL SERVICE o EXPRESSTM AYMENT BY ACCOUNT (if applicable) 1SPS0 CorPorate Acct No (cid:9) Federal AgeticyAoct. No. or Postal Service Acct. No. 'Et, VERY OPTIONS (Customer Use Only) ORIGIN (POSTAL SERVW '1S1E1 O1N1LY 1) 1 kilt'', IGNATURE REQUIRED Note: The mailer must"theck the 'Signature Required' box if the mailer. 1) ► q Military q DPO leg es the addressee's signet:re; OR 2) Purchases additional insurance; OR 3) Purchases COD service; OR 4) h0 ZIP Code 'iirshases RetprivRecerpt service. If the box is not checket (cid:9) Postal SeMce will leave the item 0 the addressee's nail receOOR*nPttre.enrstW (cid:9) :!0•?'4 (cid:9) #1*' (cid:9)ilic.,r.610•(cid:9) 012 . (cid:9) • V041 • lerNo Saturday DelWery (delivered next business day) DT) q Sunday/Holiday Delivereequired (additional fee, where available') cceptrA/D V.,,aeduled Delivery Time Insurance Fee . q 10:30 AM Delivery Required (additional fee, where available') Le$0:30 AM q 3:00 PM FO: (P'LREeAfSeEr .P tRoI NUTS) PS.com° or local Post OfficPeH-O bfNoEr (cav. e6a11(.) 4sD ogfo rdiaf,m I ty icfo::cents 1:111 k 1C0I: 3102 ANMO ODeNli very Fee Return Receipt Fee TLirvaen sApnoimrtaatli on Fee T'5e3Y3 a v5(cid:9) aatoito e q Flat Rate $S unday/Holiday Premium Fee $To tal Postage & Fees $ (00 0 $ reYa5 Av5Y-1 , DELIVERY (POSTAL SERVICE USE ONLY) aelivery Attempt (MM/DD/YY) Time (cid:9) Employee Signature :4DIRES9ONLY) 0q APMM Delivery Attempt (MM/DO/YY) Time Employee Signature n For pickup or USPS Tracking'', visit USPS.com or call 800-222-1811. q AM n $100.00 insurance included. q PM LABEL 11-B, SEPTEMBER 2015 PSN 7690-02-000-9996 2-CUSTOMER COPY