Original Prescription
at 9:21, eRx #: 7982
ELECTRONIC PRESCRIPTION
Betty L. Moore
932 Illinois
Date: 4/12/20XX
Metoclopramide 10 mg Tablet
Dispense 120
Sig: i po ac and hs
Refills: 0
Dr. Carolyn Abman
1315 W. 12th Street
BA4132647
DAW:
Prescription Origin Code: 3
Pharmacist Notes:
Dispensing Documentation
Rx #: 665997
Dispensing Date: 5/15/20XX
Patient: Betty L. Moore
Doctor: Carolyn Abman
DEA: BA4132647
NDC: 16714-0062-04
RPh Initials: HCA
Drug: Metoclopramide 10 mg Tablet
Manufacturer: Northstar
DAW Code: 0
SIG: T,1,TAB,PO,ACHS
Fill Type: Refill
Fill Number: 2
Last Fill Date: 4/12/20XX
Refills Remaining: 0
Quantity: 120
Day Supply: 30
Drug Unit Cost: $0.27
Dispensing Fee: $1.75
Total Cost: $34.15
Signature Log
Signature:
George Moore
Rx Number:
665997
Fill Date Date:
5/15/20XX
Pick-up Date:
5/15/20XX
RPh Counseling:
Decline