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99494053
2/8/20XX
Betty Moore
George Platz
Take 1 tablet by mouth once daily.
Furosemide 200 mg Tablets
90
4
2/2/20XX
Qualitest
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00603-3739-21
Quantity: 90
Days Supply: 90
AWP Cost/Unit: $0.16
Total Drug Cost: $16.00
Dispensing Fee: $2.00
Total Billed: $18.00
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00603-3739-21
Quantity: 90
Days Supply: 90
AWP Cost/Unit: $0.16
Total Drug Cost: $16.00
Dispensing Fee: $2.00
Total Billed: $18.00
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 99494053
Dispensing Date: 2/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/8/20XX
Initials: RPh
Drug Manu: Qualitest
Rx Documentation
Dispensing Date: 2/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/8/20XX
Initials: RPh
Drug Manu: Qualitest
