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1045329
12/1/20XX
Ginny Williams
James T. Warren
Take 1 tablet by mouth once daily for birth control.
Nextstellis 3 mg/14.2 mg Tablets
84
3
11/28/20XX
Mayne Pharma
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 4
Pharmacy DAW Code: 1
Drug NDC: 51862-0258-01
Quantity: 84
Days Supply: 84
AWP Cost/Unit: $8.71
Total Drug Cost: $731.64
Dispensing Fee: $2.00
Total Billed: $733.64
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 4
Pharmacy DAW Code: 1
Drug NDC: 51862-0258-01
Quantity: 84
Days Supply: 84
AWP Cost/Unit: $8.71
Total Drug Cost: $731.64
Dispensing Fee: $2.00
Total Billed: $733.64
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 1045329
Dispensing Date: 12/1/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 12/1/20XX
Initials: RPh
Drug Manu: Mayne Pharma
Rx Documentation
Dispensing Date: 12/1/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 12/1/20XX
Initials: RPh
Drug Manu: Mayne Pharma
