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6458971
4/3/20XX
Kyle O. Bruno
George Platz
Apply a thin film to the affected skin areas twice daily.
Fluticasone Propionate 0.005% Topical Ointment
15 g
3
4/2/20XX
Perrigo
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 45802-0221-35
Quantity: 15 g
Days Supply: 30
AWP Cost/Unit: $1.20
Total Drug Cost: $18.00
Dispensing Fee: $2.00
Total Billed: $20.00
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 45802-0221-35
Quantity: 15 g
Days Supply: 30
AWP Cost/Unit: $1.20
Total Drug Cost: $18.00
Dispensing Fee: $2.00
Total Billed: $20.00
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 6458971
Dispensing Date: 4/3/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 4/3/20XX
Initials: RPh
Drug Manu: Perrigo
Rx Documentation
Dispensing Date: 4/3/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 4/3/20XX
Initials: RPh
Drug Manu: Perrigo
