Remote Filling Verification - Click on Error(s)
9361456
3/8/20XX
Charles O. Elder
Carolyn Abman
Take 1 tablet by mouth once daily for ADHD.
Methylphenidate 18 mg Extended-Release Tablet
30
0
3/8/20XX
Camber
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 31722-0952-01
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $6.50
Total Drug Cost: $195.00
Dispensing Fee: $2.00
Total Billed: $197.00
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 31722-0952-01
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $6.50
Total Drug Cost: $195.00
Dispensing Fee: $2.00
Total Billed: $197.00
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 9361456
Dispensing Date: 3/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 3/8/20XX
Initials: RPh
Drug Manu: Camber
Rx Documentation
Dispensing Date: 3/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 3/8/20XX
Initials: RPh
Drug Manu: Camber
