Form 1 340BManufacturerChangeForm Revised

340B MANUFACTURER CHANGE FORM
The original contact person or signatory to the Pharmaceutical Pricing Agreement should e-mail the completed
form to the Office of Pharmacy Affairs at [email protected]; submission by anyone else may result in significant delays. Requestors will be notified when the changes have been made.

340B Manufacturer Labeler Code:
As listed on HRSA OPA’s public Web site

Complete only information that is to be changed
Manufacturer Name:
Sub-Division Name:
New Physical Address:
New Physical Address City:
New Physical Address State, Zip:
CMS Termination Date:
New Contact Person:
New Contact Title:
New Contact Phone #:
New Contact Fax #:
New Contact E-mail Address:
Comments:

Note: The original authorizing signature on the PPA cannot be changed.

SUBMIT FORM TO :::::::::::::::::::::::> [email protected]
Update of this information is subject to approval and verification by the Office of Pharmacy Affairs.