Original Prescription
Dr. Samuel Bernstein
3-C Medical Arts Building
Charles O. Elder
940 Popular
2/4/20XX
Pulmozyme 2.5 mg/2.5 mL Inhalation Solution
Dispense 30 ampules
Sig: Inhale 2.5 mg (1 ampule) via nebulizer QD
5
Samuel Bernstein
DAW: substitution permitted
Prescription Origin Code: 4
Pharmacist Notes:
Regina Smith
Prescription Origin Code: 4
Pharmacist Notes:
Dispensing Documentation
Rx #: 690122
Dispensing Date: 8/2/20XX
Patient: Charles O. Elder
Doctor: Samuel Bernstein
DEA: AB1294824
NDC: 50242-0100-40
RPh Initials: WED
Drug: Pulmozyme 1 mg/mL Inhalation Solution
Manufacturer: Genetech
DAW Code: 0
SIG: Inhale the contents of 1 ampule (2.5 mg),PO,via nebulizer,QD
Fill Type: Refill
Fill Number: 6
Last Fill Date: 7/3/20XX
Refills Remaining: 0
Quantity: 90
Day Supply: 30
Drug Unit Cost: $35.43
Dispensing Fee: $1.75
Total Cost: $3190.45
Signature Log
Signature:
Georgia Elder
Rx Number:
690122
Fill Date Date:
8/2/20XX
Pick-up Date:
8/3/20XX
RPh Counseling:
Decline