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RTF Template

Chief Pharmaceutical Inspectorate

UNION FORMAT FOR A WHOLESALE DISTRIBUTION AUTHORISATION

Human medicinal products

1. Authorisation Number	:	GIF-N-411/1080/1-13/TL/15
2. Name of Authorisation Holder	:	Boehringer Ingelheim Sp. z o.o. (ORG-100004467 / LOC-100073948)
3. Address(es) of Site(s)	:	Ul. Logistyki 3, Mszczonow, Mazowieckie, 96-320, Poland

4. Legally registered address of Authorisation Holder	:	Ul. Jozefa Piusa Dziekonskiego 3, Warsaw, 00-769
5. Scope of authorisation	:	ANNEX 1
6. Legal basis of authorisation	:	Art. 77(1) of Directive 2001/83/EC
7. Name of responsible officer of the competent authority of the member state granting the wholesale distribution authorisation	:	Confidential, Confidential
8. Signature	:
9. Date	:	2026-09-22
10. Annexes attached	:	Annex 1 Scope of wholesale distribution authorisation Annex 2 (Optional) Address(es) of contract wholesale distribution sites and their authorisation number Annex 3 (Optional) Name(s) of responsible person(s) Annex 4 (Optional) Date of Inspection on which authorisation was granted Annex 5 (Optional) Additional provisions based on national requirements

ANNEX 1

SCOPE OF WHOLESALE DISTRIBUTION AUTHORISATION

Name and address of the site: Boehringer Ingelheim Sp. z o.o.

(ORG-100004467 / LOC-100069216)

, Ul. Logistyki 3, Mszczonow, Mazowieckie, 96-320, Poland

Human medicinal products

1. MEDICINAL PRODUCTS

1.1. with a Marketing Authorisation or registration in EEA country(s)

2. AUTHORISED WHOLESALE DISTRIBUTION OPERATIONS

2.1. Procurement

2.2. Holding

2.3. Supply

3. MEDICINAL PRODUCTS WITH ADDITIONAL REQUIREMENTS

3.2. Products requiring low temperature handling

3.2.1. Temperatures between 2 to 8 °C

3.3. Other products: (please specify here or make a reference to Annex 5) Cytostatyczne produkty lecznicze

Any restrictions or clarifying remarks (for all users): Przedmiotem obrotu będą w szczególności produkty lecznicze, dla których Boehringer Ingelheim Sp. z o.o. jest dystrybutorem na terytorium Polski. Są to produkty lecznicze podmiotu: Boehringer Ingelheim International GmbH, Binger Strasse, 173, D-55216 Ingelheim am Rhein, Niemcy.

Union Format for a Wholesale Distribution Authorisation	GIF-N-411/1080/1-13/TL/15
	Page 1

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