Notice2022-07718
Christopher King, C.N.P.; Decision and Order
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Published
April 11, 2022
Issuing agencies
Justice DepartmentDrug Enforcement Administration
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<title>Federal Register, Volume 87 Issue 69 (Monday, April 11, 2022)</title>
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[Federal Register Volume 87, Number 69 (Monday, April 11, 2022)]
[Notices]
[Pages 21209-21212]
From the Federal Register Online via the Government Publishing Office [<a href="http://www.gpo.gov">www.gpo.gov</a>]
[FR Doc No: 2022-07718]
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DEPARTMENT OF JUSTICE
Drug Enforcement Administration
Christopher King, C.N.P.; Decision and Order
On December 18, 2019, a former Assistant Administrator, Diversion
Control Division, Drug Enforcement Administration (hereinafter, DEA or
Government), issued an Order to Show Cause (hereinafter, OSC) to
Christopher C. King, N.P. (hereinafter, Applicant) of Manchester,
Maine. Request for Final Agency Action (hereinafter, RFAA), Exhibit
(hereinafter, RFAAX) 2 (OSC), at 1. The OSC proposed to deny
Applicant's DEA Certificate of Registration application, Number
W19022896M, as well as to deny any pending applications for renewal or
modification of such registration and any applications for any other
registrations pursuant to 21 U.S.C. 824(a)(4) and 823(f), because
``[Applicant's] registration is inconsistent with the public
interest.'' Id.
The OSC alleged that Applicant had ``exhibited negative experience
in handling controlled substances . . . and [had] failed to comply with
applicable federal and state laws relating to controlled substances.''
Id. at 2. Specifically, the OSC alleged that, while employed at Mercy
Hospital from April 10, 2013, to June 13, 2013, Applicant diverted
controlled substances on at least two different occasions in violation
of federal and state law. Id. at 4-6. The OSC also alleged that, while
employed at St. Mary's Regional Medical Center (hereinafter, St. Mary's
Hospital) from August 25, 2014, until November 1, 2016, Applicant
diverted controlled substances on at least five different occasions in
violation of federal and state law. Id. at 2-3.
The OSC notified Respondent of the right to request a hearing on
the allegations or to submit a written statement, while waiving the
right to a hearing, the procedures for electing each option, and the
consequences for failing to elect either option. Id. at 3 (citing 21
CFR 1301.43). The OSC also notified Respondent of the opportunity to
submit a corrective action plan. Id. at 6-7 (citing 21 U.S.C.
824(c)(2)(C)).
Adequacy of Service
In a Declaration dated August 23, 2021, a Diversion Investigator
(hereinafter, the DI) assigned to the Manchester District Office stated
that on December 18, 2019, she sent a copy of the OSC to ``both
[Applicant's] registered and mailing address via First Class Mail'' and
``sent the [OSC] via certified mail on the following day.'' DI's
Declaration, at 2. The DI stated that on December 19, 2019, she
``contacted [Applicant] by phone at the mobile number listed on his
application.'' Id. According to the DI, she ``explained what an [OSC]
was, and requested that [Applicant] contact [her] when he received a
copy of the [OSC].'' Id. The DI stated that on December 26, 2019, she
received an email from Applicant that read, `` `I have received the
hard copy of the [OSC] in the mail. I do not want to pursue this matter
and do not feel it is necessary to meet and discuss.' '' Id.; see also
RFAAX 3 (email from Applicant).
The Government forwarded its RFAA, along with the evidentiary
record, to this office on August 26, 2021. In its RFAA, the Government
represents that Applicant did not request a hearing. RFAA, at 1. The
Government requests that ``the Administrator issue a final order
denying the DEA Certificate of Registration application for
[Applicant]'' because ``Applicant's [r]egistration is not in the public
interest.'' Id.
Based on the DI's Declaration, the Government's written
representations, and my review of the record, I find that the
Government accomplished service of the OSC on Applicant on or before
December 26, 2019. I also find that more than thirty days have now
passed since the Government accomplished service of the OSC. Further,
based on the DI's Declaration, the Government's written
representations, and my review of the record, I find that neither
Applicant, nor anyone purporting to represent Applicant, requested a
hearing, submitted a written statement while waiving Applicant's right
to a hearing, or submitted a corrective action plan. Accordingly, I
find that Applicant has waived the right to a hearing and the right to
submit a written statement and corrective action plan. 21 CFR
1301.43(d) and 21 U.S.C. 824(c)(2)(C). I, therefore, issue this
Decision and Order based on the record submitted by the Government,
which constitutes the entire record before me. 21 CFR 1301.43(e).
I. Findings of Fact
A. Application for DEA Registration
On March 12, 2019, Applicant applied for a DEA Certificate of
Registration as a practitioner in Schedules II through V with a
proposed registered address of 29 Bowdoin St, Manchester, ME 04351.
RFAAX 1, at 1. Applicant's application was assigned Control No.
W19022896M. Id.
B. Government's Case
The Government's RFAA includes the DI's Declaration and 10 attached
Exhibits, including a copy of Applicant's application for DEA
registration, various documents pertaining to the drug diversion
allegations against Applicant at both St. Mary's Hospital and Mercy
Hospital, and a copy of a Consent Agreement between Applicant and the
Maine Board of Nursing in which Applicant's license to practice nursing
was suspended. See RFAAX 1-10.
The DI's Declaration described the investigation into Applicant,
including the collection of the Government's Exhibits. DI's
Declaration, at 1-3. On June 13, 2013, Mercy Hospital issued a letter
to Applicant following an investigation regarding Applicant's
``suspicious behavior'' during his shift on June 4, 2013. RFAAX 9.
According to the letter, on June 4, 2013, ``medical waste (wet bloody
paper towel, open syringe wrapper, syringe cap, open band aid wrapper,
and an open alcohol wipe wrapper) was found in the bathroom in the
staff break room.'' Id. Applicant's nurse manager ``had noted that
[Applicant] had recently come into the area and had been in the
bathroom.'' Id. According to the letter, video footage of the Emergency
Department area prior to the medical waste being found was reviewed,
and Applicant was observed pulling Dilaudid from the Pyxis machine and
then entering the patient area for several minutes. Id. The video
footage showed Applicant going to a supply cart and putting supplies in
his pants pocket, then exiting the Emergency Department and entering
the staff break room around the same time that Applicant's nurse
manager had seen Applicant enter the bathroom. Id. The video footage
showed Applicant returning to the Emergency Department several minutes
later and going immediately to a sharps disposal container, where he
pulled something from his pants pocket to dispose of in that container.
Id. Finally, the video footage showed Applicant requesting an
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additional dose of Dilaudid from the ordering physician for the
patient. Id.
According to the letter, after review of Applicant's other worked
shifts since his start at Mercy Hospital, there was ``further concern
that similar behavior occurred on another shift.'' Id. During a meeting
with Applicant on June 4, 2013, Applicant ``indicated that the patient
did receive both doses of Dilaudid on that day; however, [Applicant
was] unable to provide a clear answer as to why [he] had put a sharp in
[his] pocket and later disposed of it [ ] when there are sharps
containers in every patient bay[ ].'' Id. Moreover, during a phone
conversation on June 12, 2013, Applicant ``declined to return to Mercy
[Hospital] to participate in a follow-up conversation to [the]
investigation.'' Id. According to the letter, Applicant was told that
because of his behavior, Mercy Hospital had concerns that he may have
been diverting medication, and consequently, Applicant's employment at
Mercy Hospital was terminated effective June 13, 2013. Id.
On November 1, 2016, a Risk Manager at St. Mary's Hospital issued a
Memorandum to the HR department regarding an ``Investigation of
Suspicion of Drug Diversion.'' RFAAX 6, at 1. According to the
Memorandum, on September 24, 2016, Applicant ``was found to have pulled
a medication for another Emergency Department nurse's patient.'' Id.
Further, chart documentation ``notes the medication as `contaminated'
and another vial was pulled and given to the patient by the nurse
assigned to that patient.'' Id. The medication pulled was
``Hydromorphone 1 mg/1 mL Syringe.'' Id. According to the Memorandum,
``[w]hen handed to the other nurse, she noticed that the vial had been
accessed and reported it to the nursing supervisor who then contacted
the Director of the Emergency Department.'' Id. Staff was then
instructed to safeguard the vial so that it could be sent for testing,
with the results of the testing showing that the vial was at half
concentration, indicating that it had been tampered with. Id.; see also
RFAAX 7.
According to the Memorandum, there had been other suspicious
incidents involving Applicant and several sharps containers in the
Emergency Department. RFAAX 6, at 1. ``On one occasion, [Applicant]
lost his ring in a sharps container in the [Emergency Department].''
Id. ``On another occasion, [Applicant] was found to be bleeding from
his hand,'' and although he told staff he had cut himself on the sink,
``no blood was found on the sink but blood was noted on the sharps
container located in that area.'' Id. The Memorandum notes that
``[t]here was no confirmation that [Applicant] accessed this sharps
container.'' Id.
The Memorandum further states that ``[a] chart audit was performed
to determine Pyxis access by [Applicant]'' and ``[a] report of
[Applicant's] Pyxis access from August 25, 2016 to September 24, 2016
was run and reviewed against patient charts for that time period.'' Id.
Further, ``[i]t was also reviewed against a full Pyxis report for all
users for the same time period.'' The Memorandum states that
``[s]everal missing waste documentation was found from this initial
chart audit.'' Id. On September 3, 2016, a 1 mg/1 mL syringe of
Hydromorphone was removed, but only 0.5 mg was documented to be given
to the patient, with no waste documented for the excess controlled
substance. Id. On September 5, 2016, a 100 mcg/2 mL vial of Fentanyl
Citrate for another nurse's patient was removed, but only 50 mcg was
documented to be given to the patient, with no waste documented for the
excess medication. Id. at 2. On September 10, 2016, a 2 mg/1 mL vial of
Lorazepam was removed, but only 0.5 mg was ordered and documented to be
given to the patient, with no waste documented for the excess
controlled substance. Id. Finally, on September 11, 2016, a 100 mcg/2
mL vial of Fentanyl Citrate was removed, but only 50 mcg was ordered
and documented to be given to the patient, with no waste documented for
the excess controlled substance. Id.
On November 1, 2016, St. Mary's Hospital issued a letter to
Applicant notifying him of his immediate dismissal from employment.
RFAAX 5. In addition to the incidents of potential drug diversion
previously identified in the above-described Memorandum, the letter
also stated that Applicant ``falsified and omitted pertinent facts from
[his] St. Mary's [Hospital] Employment Application by indicating that
[his] prior employment at CMMC was still `present' and for omitting
pertinent employment information for [his] work and termination from
Mercy Hospital in 2013.'' Id.
On October 16, 2017, Applicant signed a Consent Agreement for
Reprimand, Suspension, and Probation (hereinafter, Consent Agreement)
issued by the State of Maine Board of Nursing (hereinafter, the Board).
RFAAX 10, at 1 and 5. The Consent Agreement includes facts pertaining
to Applicant's alleged diversion while employed at St. Mary's Hospital,
along with additional facts, such as that Applicant ``has a March 31,
2014 letter of concern on file with the Board in which the Board
communicates its concern regarding `the importance of the proper
administration, waste and disposal of scheduled drugs in any employment
setting.' '' Id. at 1-2. By signing the Consent Agreement, Applicant
agreed to accept a Reprimand and agreed that his license would be
suspended for one year followed by at least two years of probation. Id.
at 2-3. Applicant also agreed that during the period of suspension, he
would not ``work in any capacity requiring a nursing license'' and that
he would continue to participate in the Maine Medical Professionals
Health Program (hereinafter, MPHP) and ``remain in compliance with all
the terms of his current MPHP monitoring agreement.'' Id. at 2.
II. Discussion
A. 21 U.S.C. 823(f): The Five Public Interest Factors
Pursuant to section 303(f) of the CSA, ``[t]he Attorney General
shall register practitioners . . . to dispense . . . controlled
substances . . . if the applicant is authorized to dispense . . .
controlled substances under the laws of the State in which he
practices.'' 21 U.S.C. 823(f). Section 303(f) further provides that an
application for a practitioner's registration may be denied upon a
determination that ``the issuance of such registration . . . would be
inconsistent with the public interest.'' Id. In making the public
interest determination, the CSA requires consideration of the following
factors:
(1) The recommendation of the appropriate State licensing board
or professional disciplinary authority.
(2) The applicant's experience in dispensing, or conducting
research with respect to controlled substances.
(3) The applicant's conviction record under Federal or State
laws relating to the manufacture, distribution, or dispensing of
controlled substances.
(4) Compliance with applicable State, Federal, or local laws
relating to controlled substances.
(5) Such other conduct which may threaten the public health and
safety.
21 U.S.C. 823(f).
The DEA considers these public interest factors in the disjunctive.
Robert A. Leslie, M.D., 68 FR 15227, 15230 (2003). Each factor is
weighed on a case-by-case basis. Morall v. Drug Enf't Admin., 412 F.3d
165, 173-74 (D.C. Cir. 2005). Any one factor, or combination of
factors, may be decisive. David H. Gillis, M.D., 58 FR 37507, 37508
(1993). Thus, there is no need to enter findings on each of the
factors. Hoxie v. Drug Enf't Admin., 419 F.3d 477, 482 (6th Cir. 2005).
Furthermore, there is no
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requirement to consider a factor in any given level of detail. Trawick
v. Drug Enf't Admin., 861 F.2d 72, 76-77 (4th Cir. 1988). The balancing
of the public interest factors ``is not a contest in which score is
kept; the Agency is not required to mechanically count up the factors
and determine how many favor the Government and how many favor the
registrant. Rather, it is an inquiry which focuses on protecting the
public interest . . . .'' Jayam Krishna-Iyer, M.D., 74 FR 459, 462
(2009). When deciding whether registration is in the public interest,
the DEA must consider the totality of the circumstances. See generally
Joseph Gaudio, M.D., 74 FR 10083, 10094-95 (2009) (basing sanction on
all evidence on record).
The Government does not dispute that Applicant holds a valid state
nursing license and is authorized to dispense controlled substances in
the State of Maine where he practices. See OSC, at 2. While I have
considered all of the public interest factors \1\ in 21 U.S.C. 823(f),
the public interest factors that are most relevant to the Government's
case for denial of Applicant's application are Public Interest Factors
One, Two, and Four. See RFAA, at 5-6. Moreover, the Government has the
burden of proof in this proceeding. 21 CFR 1301.44. I find that the
Government's evidence with respect to Factors Two, and Four satisfies
its prima facie burden of showing that Applicant's registration would
be ``inconsistent with the public interest.'' 21 U.S.C. 824(f).
Specifically, I find that the record contains substantial evidence that
Applicant violated both Maine law and federal law when he diverted
controlled substances from Mercy Hospital and St. Mary's Hospital. I
further find that Applicant failed to provide evidence to rebut the
Government's prima facie case.
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\1\ As to Factor Three, there is no evidence in the record that
Applicant has been convicted of an offense under either federal or
state law ``relating to the manufacture, distribution, or dispensing
of controlled substances.'' 21 U.S.C. 823(f)(3). However, as Agency
cases have noted, there are a number of reasons why a person who has
engaged in criminal misconduct may never have been convicted of an
offense under this factor, let alone prosecuted for one. Dewey C.
MacKay, M.D., 75 FR 49956, 49973 (2010). Agency cases have therefore
found that ``the absence of such a conviction is of considerably
less consequence in the public interest inquiry'' and is therefore
not dispositive. Id.
As to Factor Five, the Government's evidence fits squarely
within the parameters of Factors One, Two, and Four and does not
raise ``other conduct which may threaten the public health and
safety.'' 21 U.S.C. 823(f)(5). Accordingly, Factor Five does not
weigh for or against Applicant.
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1. Factor One
In determining the public interest under Factor One, the
``recommendation of the appropriate State licensing board or
professional disciplinary authority'' shall be considered. 21 U.S.C.
823(f)(1). ``Two forms of recommendations appear in Agency decisions:
(1) A recommendation to DEA directly from a state licensing board or
professional disciplinary authority (hereinafter, appropriate state
entity), which explicitly addresses the granting or retention of a DEA
COR; and (2) the appropriate state entity's action regarding the
licensure under its jurisdiction on the same matter that is the basis
for the DEA OSC.'' John O. Dimowo, 85 FR 15800, 15809 (2020); see also
Vincent J. Scolaro, D.O., 67 FR 42060, 42065 (2002) (``While the State
Board did not affirmatively state that the Respondent could apply for a
DEA registration, [the ALJ] found that the State Board by implication
acquiesced to the Respondent's application because the State Board has
given state authority to the Respondent to prescribe controlled
substances.'').
As previously discussed, on October 16, 2017, Applicant entered
into a Consent Agreement issued by the Board. RFAAX 10, at 1 and 5. The
Board's Consent Agreement includes some of the allegations against
Applicant that were addressed in the OSC and RFAA--namely, those
pertaining to Applicant's alleged diversion while employed at St.
Mary's Hospital. Id. at 1-2. Further, the Consent Agreement includes
additional facts related to Applicant's alleged history of diversion
such as that Applicant ``has a March 31, 2014 letter of concern on file
with the Board in which the Board communicates its concern regarding
`the importance of the proper administration, waste and disposal of
scheduled drugs in any employment setting.' '' Id. at 2. The Consent
Agreement suspends Applicant's license for one year followed by at
least two years of probation. Id. at 2-3. The Consent Agreement also
prohibited Applicant from ``work[ing] in any capacity requiring a
nursing license'' during the suspension and required him to ``continue
to participate in the MPHP and remain in compliance with all the terms
of his current MPHP monitoring agreement.'' Id. at 2.
While the Board's Consent Agreement is not a ``direct
recommendation'' for purposes of Factor One, it does indicate a
recommendation by the appropriate state entity regarding a large
portion of the allegations and evidence before me. John O. Dimowo, 85
FR at 15180. The Consent Order makes clear that the Board was aware of
Applicant's alleged diversion incidents from his time as an employee at
St. Mary's Hospital. The Consent Order also makes clear that the Board
was aware that Applicant had a history of diversion allegations against
him by including in its factual findings that, in March 2014, Applicant
received a letter of concern from the Board that alluded to possible
diversion in an employment setting. The Consent Order does not,
however, make clear whether the Board was aware of Applicant's alleged
diversion incidents from his time as an employee at Mercy Hospital nor
whether the 2014 letter of concern was in reference to those
allegations or something else. Additionally, the Board implemented a
multi-year disciplinary action that included a year of total suspension
from practice followed by a probationary period in which Applicant's
practice would be ``restricted to structured settings with on-site
supervision.'' RFAAX 10, at 3. The Board also required that Applicant
``sign a monitoring agreement with the MPHP, to remain in effect for at
least two (2) years of [his] employment in the practice of nursing.''
Id.
The Board's Consent Agreement is not dispositive of the public
interest inquiry in this case. The Board's suspension of Applicant's
nursing license, as well as its probationary conditions, do not
indicate a substantial amount of trust in Applicant. Ultimately, I find
the Board's Consent Agreement to weigh slightly in favor of Applicant,
but its weight is also minimized by the ambiguity regarding the Board's
awareness of the full extent of Applicant's history of diversion
allegations, the sanctions imposed by the Board, and the fact that I
have no information from Applicant to mitigate the circumstances. See
John O. Dimowo, 85 FR 15810-11 (citing Brian Thomas Nichol, M.D., 83 FR
47352, 47362-63 (2018)).
2. Factors Two and Four
The unrebutted record evidence demonstrates that Applicant has a
history of diversion, which comprises multiple documented incidents
from at least two different places of employment. Although Applicant
has denied at least some of the allegations from his time as an
employee at St. Mary's Hospital, (RFAAX 10, at 1-2), Applicant
nonetheless signed the Board's Consent Agreement in which he agreed
that there was ``sufficient admissible evidence for the Board to find
that it [was] more likely than not'' that he engaged in the conduct
described in the allegations. Id. at 2. Furthermore, Applicant provided
no contrary evidence on the record. Accordingly, I find that
Applicant's history of diverting controlled substances constitutes
negative dispensing experience and weighs
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against granting Applicant's application for a registration.
Furthermore, the Government alleges that Applicant repeatedly
violated state and federal laws related to controlled substances by
diverting controlled substances on at least two different occasions
while employed at Mercy Hospital and on at least five different
occasions while employed at St. Mary's Hospital. OSC, at 2 and 4
(citing 21 U.S.C. 843(a)(3); 21 CFR 1301.22(c); 17-A Me. Rev. Stat.
Sec. 1107-A; 32 Me. Rev. Stat. Sec. 2105-A(2)(F) and (H); and Maine
State Board of Nursing Rule Ch. 4 Sec. 3(P)).
According to Maine law, ``a person is guilty of unlawful possession
of a scheduled drug if the person intentionally or knowingly possesses
what that person knows or believes to be a scheduled drug, which is in
fact a scheduled drug'' \2\ unless ``the person possessed a valid
prescription for the scheduled drug or controlled substance that is the
basis for the charge and[ ], at all times, the person intended the drug
to be used only for legitimate medical use in conformity with the
instructions provided by the prescriber and dispenser.'' Me. Rev. Stat.
Ann. tit. 17-A, Sec. Sec. 1107-A(1) and (4) (Westlaw, current with
legislation through the 2021 First Regular Session and Second Special
Session of the 130th Legislature). Further, Maine regulation states
that nurses are prohibited from engaging in unprofessional conduct as
well as from violating Board rules, including, ``[d]iverting drugs,
supplies or property of patients or health care provider[s].'' 02-380
Me. Code R. Ch. 4, Sec. 3(P) (Westlaw, current through the June 16,
2021 Maine Weekly Rule Notice).
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\2\ I am not including a finding on this particular state law,
because the Government failed to provide any arguments related to
these allegations in the RFAA or further information related to the
Maine schedules. It is clear to me that Applicant's registration is
not in the public interest due to his diversion in spite of the
limited arguments in the RFAA.
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Under federal law, it is unlawful ``to acquire or obtain possession
of a controlled substance by misrepresentation, fraud, forgery,
deception, or subterfuge.'' 21 U.S.C. 843(a)(3). Federal law also
states that ``[a]n individual practitioner who is an agent or employee
of a hospital or other institution may, when acting in the normal
course of business or employment, administer, dispense, or prescribe
controlled substances under the registration of the hospital or other
institution which is registered in lieu of being registered him/
herself, provided that . . . [s]uch dispensing, administering or
prescribing is done in the usual course of his/her professional
practice.'' 21 CFR 1301.22(c). Federal law defines an individual
practitioner as an ``individual licensed, registered, or otherwise
permitted, by the United States or the jurisdiction in which he/she
practices, to dispense a controlled substance in the course of
professional practice.'' 21 CFR 1300.01.
In this case, the evidence supports a finding that Applicant
diverted controlled substances on at least two different occasions
while employed at Mercy Hospital and on at least five different
occasions while employed at St. Mary's Hospital. In doing so, he
clearly acted outside of the usual course of his professional practice
and dispensed controlled substances in violation of state and federal
law. Given the repeated nature of Applicant's violations of federal and
state regulations related to controlled substances, I find that Factors
Two and Four strongly weigh against Applicant's registration and I find
Applicant's registration to be inconsistent with the public interest in
balancing the factors in 21 U.S.C. 823(f).
III. Sanction
Where, as here, the Government has met its prima facie burden of
showing that grounds for denial exist, the burden shifts to the
Applicant to show why he can be entrusted with a registration. Garrett
Howard Smith, M.D., 83 FR 18882, 18910 (2018) (collecting cases). In
this case, Applicant did not request a hearing and did not avail
himself of the opportunity to refute the Government's case. See RFAA,
at 1 and RFAAX 3. As such, Applicant has not expressed any remorse nor
provided any assurances that he would implement remedial measures to
ensure his misconduct is not repeated, and such silence weighs against
his registration. Zvi H. Perper, M.D., 77 FR 64131, 64142 (2012)
(citing Medicine Shoppe-Jonesborough, 73 FR 363, 387 (2008)); see also
Samuel S. Jackson, D.D.S., 72 FR 23848, 23853 (2007). Further, due to
the lack of a statement or testimony from Applicant, it is unclear
whether Applicant can be entrusted with a DEA registration. Therefore,
I find that sanction is appropriate to protect the public from a
recurrence of Applicant's unlawful actions. See Leo R. Miller, M.D., 53
FR 21931, 21932 (1988). Accordingly, I shall order the sanctions
requested by the Government, contained in the Order below.
Order
Pursuant to 28 CFR 0.100(b) and the authority vested in me by 21
U.S.C. 823(f) and 21 U.S.C. 824(a), I hereby deny the pending
application for a Certificate of Registration, Control Number
W19022896M, submitted by Christopher C. King, N.P., as well as any
other pending application of Christopher C. King, N.P. for additional
registration in Maine. This Order is effective May 9, 2022.
Anne Milgram,
Administrator.
[FR Doc. 2022-07718 Filed 4-8-22; 8:45 am]
BILLING CODE 4410-09-P
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