Remote Filling Verification - Click on Error(s)
84103201
5/22/20XX
Stanley M. Bontrager
Samuel Bernstein
Take 1 teaspoonful (5 mL) by mouth every 12 hours as needed for cough.
Hydrocodone/Chlorpheniramine 10 mg/8 mg/5 mL ER Oral Suspension
90 mL
0
5/20/20XX
Tris
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 3
Pharmacy DAW Code: 0
Drug NDC: 27808-0086-02
Quantity: 90 mL
Days Supply: 9
AWP Cost/Unit: $0.60
Total Drug Cost: $54.00
Dispensing Fee: $2.00
Total Billed: $56.00
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 3
Pharmacy DAW Code: 0
Drug NDC: 27808-0086-02
Quantity: 90 mL
Days Supply: 9
AWP Cost/Unit: $0.60
Total Drug Cost: $54.00
Dispensing Fee: $2.00
Total Billed: $56.00
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 84103201
Dispensing Date: 5/22/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 5/22/20XX
Initials: RPh
Drug Manu: Tris
Rx Documentation
Dispensing Date: 5/22/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 5/22/20XX
Initials: RPh
Drug Manu: Tris
