Original Prescription
Dr. Harold L. Green
2-G Medical Arts Building
Robbie Roberts
5050 Plaza Hill Road
11/6/20XX
Concerta 27 mg Tablet
Dispense 30
Sig: i po QD for ADHD
Cancelled - PPM - 11/8/20XX
0
Harold L. Green
DAW:
substitution permitted
Prescription Origin Code: 1
Pharmacist Notes:
Dispensing Documentation
Rx #: 298748
Dispensing Date: 11/8/20XX
Patient: Robbie Roberts
Doctor: Harold L. Green
DEA: AG1294230
NDC: 00591-2716-01
RPh Initials: PPM
Drug: Methylphenidate HCl 27 mg ER Tablet
Manufacturer: Watson
DAW Code: 0
SIG: T,1,TAB,PO,QD,for ADHD
Fill Type: New
Fill Number: 1
Last Fill Date: 11/8/20XX
Refills Remaining: 0
Quantity: 30
Day Supply: 30
Drug Unit Cost: $6.38
Dispensing Fee: $1.75
Total Cost: $193.15
Signature Log
Signature:
Robert Roberts
Rx Number:
298748
Fill Date Date:
11/8/20XX
Pick-up Date:
11/9/20XX
RPh Counseling:
Accept