Original Prescription
at 9:17, eRx #: 7975
ELECTRONIC PRESCRIPTION
Mrs. Harold Elder
940 Oak Street
Date: 10/22/20XX
TMP/SMX DS Tablets
Dispense 2 weeks
Sig: i po BID x 2 weeks
Refills: 0
Dr. Samuel Bernstein
3-C Medical Arts Building
AB1294824
DAW: substitution permitted
Prescription Origin Code: 3
Pharmacist Notes:
Dispensing Documentation
Rx #: 802369
Dispensing Date: 10/22/20XX
Patient: Mrs. Harold Elder
Doctor: Samuel Bernstein
DEA: AB1294824
NDC: 53746-0272-05
RPh Initials: EOP
Drug: Trimethoprim/Sulfamethoxazole 160 mg/800 mg Tablet
Manufacturer: Amneal
DAW Code: 0
SIG: T,1,TAB,PO,BID,X14D
Fill Type: New
Fill Number: 1
Last Fill Date: 10/22/20XX
Refills Remaining: 0
Quantity: 28
Day Supply: 14
Drug Unit Cost: $0.91
Dispensing Fee: $1.75
Total Cost: $27.23
Signature Log
Signature:
Mrs. Harold Elder
Rx Number:
802369
Fill Date Date:
10/22/20XX
Pick-up Date:
10/22/20XX
RPh Counseling:
Accept