Original Prescription
at 9:13, eRx #: 2646
ELECTRONIC PRESCRIPTION
Evelyn Johnson
1426 Pinecone Drive
Date: 4/20/20XX
Actonel 35 mg Tablet
Dispense 4
Sig: i po qweek
Refills: 6
Dr. Samuel Bernstein
3-C Medical Arts Building
AB1294824
DAW: dispense as written
Prescription Origin Code: 3
Pharmacist Notes:
Dispensing Documentation
Rx #: 541231
Dispensing Date: 6/14/20XX
Patient: Evelyn Johnson
Doctor: Samuel Bernstein
DEA: AB1294824
NDC: 00430-0472-03
RPh Initials: EED
Drug: Actonel 35 mg Tablet
Manufacturer: Warner Chilcott
DAW Code: 1
SIG: 1,TAB,PO,QWEEK
Fill Type: Refill
Fill Number: 3
Last Fill Date: 5/9/20XX
Refills Remaining: 4
Quantity: 4
Day Supply: 30
Drug Unit Cost: $35.97
Dispensing Fee: $1.75
Total Cost: $145.63
Signature Log
Signature:
Evelyn Johnson
Rx Number:
541231
Fill Date Date:
6/14/20XX
Pick-up Date:
6/15/20XX
RPh Counseling:
Decline