Original Prescription
Family Health Associates - Doctors James Warren and Norman Keyes
3-G Medical Arts Building
Teresa C. Sykes
832 Missouri Street
12/15/20XX
Ambien 5 mg Tablet
Dispense 30
Sig: i po qHS prn sleep
2
James T. Warren
AW1351977
DAW: substitution permitted
C
Prescription Origin Code: 4
Pharmacist Notes:
Yolanda Fields
Prescription Origin Code: 4
Pharmacist Notes:
Dispensing Documentation
Rx #: 255988
Dispensing Date: 12/21/20XX
Patient: Teresa C. Sykes
Doctor: James T. Warren
DEA: AW1351977
NDC: 16714-0621-01
RPh Initials: VLL
Drug: Zolpidem Tartrate 5 mg Tablet
Manufacturer: Northstar
DAW Code: 0
SIG: T,1,TAB,PO,QHS,PRN,SLEEP
Fill Type: New
Fill Number: 1
Last Fill Date: 12/21/20XX
Refills Remaining: 2
Quantity: 30
Day Supply: 30
Drug Unit Cost: $4.62
Dispensing Fee: $1.75
Total Cost: $140.35
Signature Log
Signature:
Rx Number:
255988
Fill Date Date:
12/21/20XX
Pick-up Date:
12/23/20XX
RPh Counseling:
Decline