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5311402
11/11/20XX
Edward M. Miller
Samuel Bernstein
Place 1 film under tongue and allow to completely dissolve.
Buprenorphine/Naloxone 8 mg/2 mg Sublingual Film
30
0
11/10/20XX
Alvogen
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 3
Pharmacy DAW Code: 0
Drug NDC: 47781-0357-03
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $9.15
Total Drug Cost: $274.50
Dispensing Fee: $2.00
Total Billed: $276.50
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 3
Pharmacy DAW Code: 0
Drug NDC: 47781-0357-03
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $9.15
Total Drug Cost: $274.50
Dispensing Fee: $2.00
Total Billed: $276.50
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 5311402
Dispensing Date: 11/11/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 11/11/20XX
Initials: RPh
Drug Manu: Alvogen
Rx Documentation
Dispensing Date: 11/11/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 11/11/20XX
Initials: RPh
Drug Manu: Alvogen
