Context: Timely access to emergency contraception (EC) has emerged as a major public health effort in the prevention of unintended pregnancies. The recent FDA decision to allow over-the-counter availability of emergency contraception for adult women presents important rural health implications. American women, especially those living in rural and frontier areas, have one of the highest rates of unintended and teen pregnancy among developed countries. Purpose: This study, conducted prior to the recent FDA ruling, evaluated the participation among California pharmacies in the pharmacy access program in December 2005, specifically comparing rural/frontier and urban pharmacies. Methods: The sample consisted of 862 California pharmacies, including 50 in rural/frontier areas, which were randomly selected and surveyed by telephone. Findings: The results indicated that similar proportions of rural/frontier pharmacies and urban pharmacies provided direct pharmacy access services (28% vs 22%, P = 0.32). However, of the 13 rural/frontier counties included in the survey, eight (62%) had no emergency contraception pharmacies. The rural/frontier pharmacies that provided emergency contraception services tended to be small, independent pharmacies in the most remote areas of the state. Among rural/frontier pharmacies that did not participate in the program, the primary reasons included lack of training or demand for emergency contraception. Only one rural/frontier pharmacist cited moral or religious opposition to providing emergency contraception. Conclusions: In light of the current limited over-the-counter status of emergency contraception, the role of rural and frontier pharmacies in ensuring access to emergency contraception will increase in the future.