Remote Filling Verification - Click on Error(s)
177801
6/8/20XX
Lily M. Hanson
George Platz
Take 2 tablets by mouth three times a day.
Lithium Carbonate 300 mg Tablet
180
5
6/6/20XX
Sun
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 62756-0430-88
Quantity: 180
Days Supply: 30
AWP Cost/Unit: $0.25
Total Drug Cost: $45.00
Dispensing Fee: $2.00
Total Billed: $47.00
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 62756-0430-88
Quantity: 180
Days Supply: 30
AWP Cost/Unit: $0.25
Total Drug Cost: $45.00
Dispensing Fee: $2.00
Total Billed: $47.00
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 117801
Dispensing Date: 6/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 6/8/20XX
Initials: RPh
Drug Manu: Sun
Rx Documentation
Dispensing Date: 6/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 6/8/20XX
Initials: RPh
Drug Manu: Sun
