California State Board of Pharmacy 1525 N. Market Blvd, Suite N219, Sacramento, CA 95534 Phone (916) 574-7900 Fax (915) 574-8518 Illf58? W651i?" STATE AND CONSUMER SERVICES AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR-EDMUND G. BROWN JR. CHANGE OF PERMIT REQUEST (Pharmacy, Hospital Pharmacy, Clinic, Licensed Correctional Facility, Exempt TYPE OF CHANGE Hospital, Non-Resident Pharmacy) .Jl} CHECK ALL THAT APPLY El Corporate Of?cer(s) Medical Director Transfer of 10%-49% of stock Please print or type Name of permit holder Brighton Way Pharmacy, Inc. Address of permit holder 6333 Wilshire Blvd. Number and Street Address (not change of location) El Tradestyle Name Corporation Name Telephone Number (323 551 ?1 595 City State Zip Code Los Angeles CA 90048?5702 Name of business Permit number Business phone number West Wilshire Pharmacy 379/39 (323)651-1595 Address of business Number and Street City State Zip Code 6333 Wilshire Blvd. Los Angeles CA 90048-5702 A. Corporate Officers LIST CHANGES ONLY tJnde.r ?Licensed as" list any state professional or vocational licenses held; pharmacist, physician, podiatrist, dentist orveterinarian, etc., and the license number. Non-profit organizations must list the names and titIes of persons holding corporate positions. Name of CEO Licensed as License number O?ly Certs Residence address City State Zip Code El FP CI FPC Name of President Licensed as License number For Of?ce Use Only Certs Residence address City State Zip Code El FP El FPC Name of Secretary Licensed as License number For Of?ce Use Only Certs Residence address City State Zip Code FP Cl FPC "Continue on Reverse I ?if FOROFFICE USEONLY I A. A A [555 Articles of Inc Date application completed Cashiert?ta If} [f 51' :7 ha? Name-Sm? Date changes made on system Date Ema Mimes Staff initials LVI Amt of fee rov- Name of Treasurer Licensed as License number For Of?ce Use Only Cl Certs Residence addreSS Cit State Zi Code FP l:l FPC Name of Medical Director Licensed as License number For Of?ce Use Only Certs Residence address City State Zip Code l:l FP El FPC B. Shareholders COMPLETE ONLY IF THERE IS A STOCK TRANSFER List all persons who own 10% or more of stock (use additional sheet if necessary). To whom issued Residence address telephone no. Licensed as, license no. and of Date state(s) Shares issued Shahrokh Makhani i 35054 CA 90 8/20/14 Lucena Holdings LLC n/a 10 8/20/14 Please read carefully The information wi ll be used to determine qu alifications for registration un der the California Pharmacy Law. he official responsible for information maintenance is the Executive Officer, telephone (916)574?7900, 1625 N. Market Blvd, N219, Sacramento, California 95834. The information may be transferred to another governmental agency such as a law enforcement ag ency if necessary for it to perform its duties. Each individual hasthe right to reviewthefiles or records maintained 0 them by 0 ur a gency, nless the records are identified as confidential information and exempted by Section 1798.3 of the Civil Code. Under penalty of perjury, under the laws of the State of California, each person whose signature appears below, certifies and says: (1) he/she is the owner or an officer of the applicant corporation named in the foregoing application, duly authorized to make this application on its behalf and is at least 18 years of age; (2) he/she has read the foregoing application and knows the contents thereof and that each and all statements therein made are true; (3) all supplemental statements are true and accurate; (4) the transfer application may be withdrawn by either the applicant orthe licensee with no resulting liability to the Board of Pharmacy. SIGNATURE :77 @f Shahrokh Makhani 2 Signature ofCorpor?te Officer or Owner Name (please print) Date Sherri Leon Signature of Corporate Officer or Owner Name (please print) Date 17A-12 (Rev. 3?99) IQ Name of Treasurer Licensed as License number For Of?ce Use Only El Certs si dd C?t St 2' 8083 ress 1y 88 IP 08 El FPC Name of Medical Director I Licensed as License number For Of?ce Use 0m? i Certs Residence address City State Zip Code El FP El FPC B. Shareholders COMPLETE ONLY iF THERE IS A STOCK TRANSFER List all persons who own 10% or more of stock (use additional sheet if necessary). To whom issued Residence address a telephone no. Licensed as, license no. and of Date state(s) Shares issued Shahi?okh Makhani 35054 CA 90 8/20/14 Lucena Holdings LLC n/a 10 8/20/14 Please read carefully The information wi ll be used to determine qu alifications for registration un der the California harmaoy La w. he official responsible for informationmaintenance is the Executive Officer, telephone (916)574-7900. 1625 N. Market Blvd, N219, Sacramento] California 95834. The information may be transferred to another governments! agency such as a law enforcement ag ency if necessary for it to perform its duties. Each individual hasthe right to reviewthefiles or records maintained 0 them by 0 ur agency. nless the records are identified as confidential information and exempted by Section 1798.3 of the Civil Code. Under penalty of perjury, under the laws of the State of California, each person whose signature appears below, certi?es and says: he/she is the owner or an officer of the applicant corporation named in the foregoing application, duly authorized to make this application on its behalf and is at least 18 years of age; (2) he/she has read the foregoing application and knows the contents thereof and that each and all statements therein made are true; (3) all supplemental statements are true and accurate; (4) the transfer application may be withdrawn by either the applicant orthe licensee with no resulting liability to the Board of Pharmacy. SIGNATURE [4 Shahrokh Makhani a v/ 29/ Signature of"Corpor?te Officer or Owner Name (please print) Date . Sherri Leon 7 r/ Signature of Corporate Officer or Owner Name (please print) Date mat-12 (Rey. ares) California State Board of Pharmacy 1625 N. Market Blvd. Suite N219. Sacramento. CA 95834 Phone (916) 574-7900 Fax (916) 574-8518 STATE AND CONSUMERS AFFAIRS AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. CERTIFICATION OF PERSONNEL INSTRUCTIONS: Must be completed by each owner, director, officer, major shareholder and pharmacist-in-charge. All blanks must be completed; if not applicable, enter Failure to furnish a complete explanation or any omissions will delay the processing of your application. 1. Full name (last, first, middle) Leon, Sherri Diane 2. Residence address (street, city, state, zip code) Residence telephone number 3. Are you currently licensed as a physician, podiatrist, dentist, optometrist or veterinarian in this state or any other state? If the answer is "yes," please list each license number, license type, and the state(s) where you are licensed. DYes No License Type License Number State Expiration Date 4, Is your spouse, child, parent, or other relative or any person with whom you share a financial interest, licensed in this state or any other state, as a physician, podiatrist, dentist, or veterinarian? If the answer is "yes," list the name of each I: Yes No person, their relationship to you, the license type, number and state. (Use additional sheets if necessary.) Name Relationship License Type License Number State 5. Are you currently, or have you previously been, listed as a corporate owner, manager, limited liability company member, administrator or medical director on a officer, partner, I: Yes No permit to sell, store or possess dangerous drugs or dangerous devices in this state or any other state? If "yes," please list the company name, permit type and number, position(s) held, state and expiration date. Please include information regarding cancelled permits. (Use additional sheets if necessary.) Name of company Type of permit Permit number Position held State Expiration date 17A-11 Page 1 of 4 6. Have you ever had a pharmacy permit, or any professional or vocational license or Yes NO registration denied, suspended, revoked, placed on probation or other disciplinary action taken by this or any other governmental authority in this state or any other state? If "yes," please provide permit type, action, company name (if applicable), year of action and state. (Use additional sheets if necessary.) Name of person or business Type of permit Type of Year of Action State 7. Are you currently, or have you previously been, associated in business with any person, partnership, corporation, or other entity, or shared a financial or community property Yes No interest with any person whose pharmacy permit, or any professional or vocational license was denied, suspended, revoked, or placed on probation or other disciplinary action taken, by this or any other governmental authority in this state or any other state? Ifthe answer is "yes," please list the company name, permit type, action, year of action and state. (Use additional sheets if necessary.) Name of person or business Type of permit Type of Action Year of Action State Have you ever been in violation of any provisions of pharmacy law, in this or any other state? If "yes," please list each type of violation, license type, type of action, year of action and state. (Use additional sheets if necessary.) Type of Violation License Number Type of Action Year of Action State 9. Have you ever been convicted of, or pled no contest to, a violation foreign country, the United States, any state or local jurisdiction? You must include all misdemeanor and felony convictions, regardless of the age of the conviction, including those which have been set aside and/or dismissed under Penal Code section 1000 or 1203.4. (Traffic violations of $500 or less need not be reported.) it "yes," please attach an explanation which must include the type of violation, the date, circumstances and location, and the complete penalty received. ?10. Do you have a medical condition which in any way impairs or limits your ability to practice your profession with reasonable skill and safety without exposing others to significant health and safety risks? lf"yes," attach a statement of explanation. if go directly to question 12. 'i7A?11 (Rev. 1/12) Page 2 of4 11. Are the limitations caused by your medical condition reduced or improved because you receive ongoing treatment or participate in a monitoring program? If "yes," please attach a statement of explanation; (If you do receive ongoing treatment or participate in a monitoring program, the board will make an individualized assessment of the nature, the severity and the duration of the risks associated with an ongoing medical condition so as to determine whether an unrestricted license should be issued, or whether conditions should be imposed). 12. Do you currently engage in, or have been engaged in the past two years, in the illegal Yes No use of controlled substances? lf yes," are you currently participating in a supervised rehabilitation program or professional assistance program which monitors you in order to ensure that you are not engaging in the illegal use of controlled substances? Please attach a statement of explanation. 13. VWI you work as an employee of this business? If yes, what will your responsibilities and duties be with this business? Yes NO You must provide a written explanation for all affirmative answers to questions 3 -12. Failure to do so may result in this application being deemed withdrawn as incomplete. If you are a non-pharmacist owner, partner, corporate officer, corporate director or administrator of the business, you should be aware that: any non-pharmacist owner who commits any act which would subvert or tends to subvert the efforts of the pharmacist-in-charge to comply with the laws governing the operation of the pharmacy is guilty of a misdemeanor; you may not order a pharmacist to perform any act which is prohibited by law; any violation of the Federal Food, Drug Cosmetic Act, the Federal Controlled Substance Act or any law or regulation relating to the practice of pharmacy in the State of California is grounds for suspension or revocation of the permit for which you are applying; committing any act prohibited by law, or neglecting to perform any duty required by law, could result in proceedings against the personal license of a pharmacist or could result in an action against your permit. you are not permitted to assist in any phase of compounding or dispensing of prescriptions, or to perform any of the duties which are required by law or regulation to be done by a pharmacist; (0 only a pharmacist may possess the key to the pharmacy or to the permanent barrier separating the pharmacy; (9) you may enter the pharmacy for the purpose of performing certain specified duties only when the pharmacist is present; and the pharmacist is responsible for any non-registered person allowed to enter the pharmacy. (This does not apply to hospital pharmacies or limited permits under Business and Professions Code section 4117, or Title 16, California Code of Regulations section 1714); dangerous drugs and/or devices as defined in Business and Professions Code sections 4022 and 4023 may only be sold on prescription or to persons who are licensed to handle, sell and possess such drugs. 17A-11 (Rev. 1112) Page 3 of 4 Ail items of information requested on this form are mandatory. Failure to provide any of the requested information will result in the application being deemed withdrawn as incomplete. This information will be used to determine qualifications for iicensure under California pharmacy law. The officer responsible for information maintenance is the executive officer, telephone (916) 574-7900, 1625 N. Market Blvd, Suite N219, Sacramento, CA 95834. This information may be transferred to another governmental agency, such as a law enforcement agency, if necessary for it to perform its duties. Each individual has the right to review the files or records maintained on him/her by the Board of Pharmacy, unless the records are identified as confidential information and exempted by Civil Code section 1798.3. NOTICE: Effective July 1, 2012, the State Board of Equalization and the Franchise Tax Board may share individual taxpayer information with the board. You are obligated to pay your state tax obligation. This application may be denied or your license may be suspended if the state tax obligation is not paid. I hereby certify under penalty of perjury under the laws of the State of California to the truth and accuracy ofall statements, answers and representations made in the foregoing certification of personnel form, including all supplementary statements ,and i, personally completed this certification of personnel form. i also certify that have read and understand the rules of professional conduct and have retained a copy on file. I Signature Sherri Diane Leon Date 17A-11 (Rev. 1i12) Page 4 of 4 Please print or type BUSINESS, CONSUMER SERVICES AND HOUSING AGENCY DEPARTMENT OF CONSUMER AFFAIRS GOVERNOR EDMUND G. BROWN JR. California State Board of Pharmacy 1625 N. Market Blvd. Suite N219, Sacramento, CA 95834 Phone (916) 574-7900 Parent WMWW Limited Liability Company Ownership information All blanks must be completed; if not applicable, enter West Wilshire Pharmacy Name of parent corporation or limited liability company Telephone number _l Lucena Holdings, LLC (855) 744-5791 Address Number and Street City State Zip Code 529 Goldfinch Lane Ambler, PA19044 Name address of premises Number and Street City State Zip Code 6333 Wilshire Blvd, Los Angeles. CA 90048-5702 is the parent corporation a subsidiary? Yes : No if yes, name of parent corporation corporation must also complete a Parent Corporation or Limited Liability Company Ownership information form. Please attach an organization chart. This parent A. Limited Liability Members or Manager(s) (Use additional sheets if necessary) Under the heading ?Licensed as" list any state professional or vocational licenses held; pharmacist, physician, podiatrist, dentist or veterinarian, etc, and the license number (if applicable). Non-profit organizations must list the names and titles of persons holding corporate positions. Title Licensed as, license no. Residence address telephone number and Statem Name CEO Sherri Leon PA Member ?la Gregory W. For Limited Liability Companies Only: We, the undersigned members, authorize Sherri Leon (Name of member) to sign all Board of Pharmacy forms, documents and operating conditions on our behalf. B. Corporate Officerleirectors (Top 5 of each. Use additional sheets if necessary.) Under the heading ?Licensed as" list any state professional or vocational licenses held; pharmacist, physician, podiatrist, dentist or veterinarian, etc, and the license number (if applicable). Non-profit organizations must list the names and titles of persons holding corporate positions. . Licensed as, license no. Reeldence address a telephone number and Stands) PA RP036101L Title Name CEO Sherri D. Leon Director Jamie Fleming ma C. Owners/Shareholders List all persons who own an interest (use additional sheets if necessary). List certificates chronologically, including active, cancelled, and pending issuance. If stock is pledged, include date, number of shares, and from whom to whom. Attach a copy of all stock certificates, transfer ledgers, and proof of purchase issued to date. Under the heading "Licensed as" list any state professional or vocational licenses held; pharmacist, physician1 podiatrist, dentist or veterinarian, etc, and the license number (if applicable). Residence address telephone To whom issued number Licensed as. license no. and state(s) licensed in Cert of Shares Date issued Date canceHed n/a D. Ownership if no stockholders exist, list all persons with a beneficial interest below. Name Gregory W. Residence address 8; telephone number E. Does 10% or more of the ownership rest with any other entity? Yes : No if yes, please list below Name Residence address telephone number This application must be approved by the California State Board of Pharmacy before a permit will be issued. If changes are made during the appiication process, you may need to submit a new application with the appropriate fees. Fees applied to this application are not transferable and are not refundable. Any material misrepresentation in the answer of any question is grounds for refusal or subsequent revocation of a license, and is a violation of the Penal Code of California. All items of information requested in this application are mandatory. Failure to provide any of the requested information will result in the application being rejected as incomplete. The information will be used to determine qualifications for iicensure under California Pharmacy Law. The officer responsible for information maintenance is the executive officer, (916) 574-7900, 1525 N. Market Blvd. Suite N219, Sacramento, California 95834. The information may be transferred to another governmental agency such as a law enforcement agency if necessary for it to perform its duties. Each individual has the right to review the files or records maintained on him or her by the Board of Pharmacy, unless the records are identified as confidential information and exempted by section 1798.3 of the Civil Code. ALL OWNERS AND OFFICERS DESIGNATED ON THIS FORM MUST SIGN BELOW. Under penalty of perjury, under thelaws of the State of California, each person whose signature appears below, certifies and says that: (1) he/she is the owner or an officer of the corporation or iimited liability company named on this application form. duly authorized to make this application on its behalf and is at least 18 years of age; (2) he/she has read the foregoing application-anti knows the contents thereof and that each and all statements therein made are true; (3) no person other than the appiicant or appiicants has any direct or indirect interest in the appiicant's or applicants' business to be conducted under the license for which this application is made; and (4) all suppiemental statements are true and accurate. Print NameGregory Signature Date Print NameSherri Leon Signature Date '7 /i 7 Print Name Signature Date Print Name . Signature Date Print Name Signature Date Print Name Signature Date 17A-33A (rev. Edam/are 1 Q?e first State I, JEFFREY W. BULLOCK, SECRETARY OF STATE OF THE STATE OF DELAWARE, DO HEREBY CERTIFY THE ATTACHED IS A TRUE AND CORRECT COPY OF THE CERTIFICATE OF FORMATION OF HOLDINGS, FILED IN THIS OFFICE ON THE FOURTH DAY OF AUGUST, A.D. 2014, AT 4:17 P.M. WEQZQ 5580511 8100 AUTHEN TION: 1594435 141032422 You may verify this certificate online at corp. delaware. gov/authver. .5th DATE: 08-05-14 Jeffrey W. Butlock, Secretary ofState State of Delaware Secreta of State Division 0 Cor rations Delivered 05:15 08/04/2014 FILED 04:17 RM 08/04/2014 SRV 141032422 5580511 FILE CERTIFICATE OF FORMATIOPV OF LUCENA HOLDINGS, LLC This Certi?cate of Formation of Lueena Holdings, LLC is to be ?led with the Secretary of State of the State of Delaware pursuant to Section 18?20l of the Delaware Limited Liability Company Act. 1. The name of the limited liability company is Lucena Holdings, LLC. 2. The name and street and mailing address of the initial registered of?ce and the registered agent for service of process of the limited liability company in the State of Delaware are as follows: National Corporate Research, Ltd, 615 South DuPont Highway, City of Dover, County ofKent, Delaware l9901. Dated as ofthis Bist day ofjuly, 20M.