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4955639
9/6/20XX
Mary S. Wright
Norman Keyes
Take 1 tablet by mouth four times a day for muscle spasm.
Carisoprodol 350 mg Tablet
56
0
9/5/20XX
Aurobindo
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 3
Pharmacy DAW Code: 0
Drug NDC: 65862-0158-01
Quantity: 56
Days Supply: 14
AWP Cost/Unit: $2.30
Total Drug Cost: $128.80
Dispensing Fee: $2.00
Total Billed: $130.80
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 3
Pharmacy DAW Code: 0
Drug NDC: 65862-0158-01
Quantity: 56
Days Supply: 14
AWP Cost/Unit: $2.30
Total Drug Cost: $128.80
Dispensing Fee: $2.00
Total Billed: $130.80
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 4955639
Dispensing Date: 9/6/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 9/6/20XX
Initials: RPh
Drug Manu: Aurobindo
Rx Documentation
Dispensing Date: 9/6/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 9/6/20XX
Initials: RPh
Drug Manu: Aurobindo
