Pharmacy providers already enrolled with Texas Medicaid utilize the Ownership Transfer Affidavit to notify the state of change a in pharmacy ownership.
The Pharmacy Ownership Transfer Affidavit must be submitted in conjunction with the VDP Pharmacy Enrollment Application (Form 1340 ) when an enrolled pharmacy changes ownership. The completed form must contain both the seller’s and buyer’s information and be notarized.
Mail: Vendor Drug Program (MC-2250)
Texas Health and Human Services 4900 North Lamar Blvd.
Austin, TX 78751
Questions about this form should be directed to the Vendor Drug Program by email.