Original Prescription
John R. Morgan
1824 New York Street
2/6/20XX
Lipitor 10 mg Tablet
Dispense 30
Sig: i po QD for high cholesterol
6
George Platz
Darla Henderson
Prescription Origin Code: 2
Pharmacist Notes:
Dispensing Documentation
Rx #: 784033
Dispensing Date: 7/6/20XX
Patient: John R. Morgan
Doctor: George Platz
DEA: AP7323013
NDC: 00071-0155-23
RPh Initials: NBM
Drug: Lipitor 10 mg Tablet
Manufacturer: Pfizer
DAW Code: 1
SIG: T,1,PO,QD,for high cholesterol
Fill Type: Refill
Fill Number: 5
Last Fill Date: 6/2/20XX
Refills Remaining: 2
Quantity: 30
Day Supply: 30
Drug Unit Cost: $4.72
Dispensing Fee: $1.75
Total Cost: $143.35
Signature Log
Signature:
John Morgan
Rx Number:
784033
Fill Date Date:
7/6/20XX
Pick-up Date:
7/9/20XX
RPh Counseling:
Decline