Remote Filling Verification - Click on Error(s)
4702310
3/21/20XX
Sunny Wong
James T. Warren
Take 1 tablet 3 times a day.
Metronidazole 500 mg Tablet
30
0
3/20/20XX
Actavis
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00591-5215-50
Quantity: 30
Days Supply: 10
AWP Cost/Unit: $0.75
Total Drug Cost: $22.50
Dispensing Fee: $2.00
Total Billed: $24.50
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00591-5215-50
Quantity: 30
Days Supply: 10
AWP Cost/Unit: $0.75
Total Drug Cost: $22.50
Dispensing Fee: $2.00
Total Billed: $24.50
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 4702310
Dispensing Date: 3/21/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 3/21/20XX
Initials: RPh
Drug Manu: Actavis
Rx Documentation
Dispensing Date: 3/21/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 3/21/20XX
Initials: RPh
Drug Manu: Actavis
