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8302284
2/27/20XX
Carlos Garcia
George Platz
Take 1 capsule by mouth once daily in the evening.
Olanzapine/Fluoxetine 6 mg/25 mg Capsule
30
1
2/22/20XX
Teva
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 3
Pharmacy DAW Code: 0
Drug NDC: 00093-5504-56
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $14.48
Total Drug Cost: $434.40
Dispensing Fee: $2.00
Total Billed: $436.10
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 3
Pharmacy DAW Code: 0
Drug NDC: 00093-5504-56
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $14.48
Total Drug Cost: $434.40
Dispensing Fee: $2.00
Total Billed: $436.10
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 8302284
Dispensing Date: 2/27/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/27/20XX
Initials: RPh
Drug Manu: Teva
Rx Documentation
Dispensing Date: 2/27/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/27/20XX
Initials: RPh
Drug Manu: Teva
