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9956633
12/17/20XX
Tran Nguyen
Samuel Bernstein
Take 1 tablet by mouth at bedtime as needed for sleep.
Zolpidem 10 mg Tablet
20
0
12/10/20XX
Teva
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 2
Pharmacy DAW Code: 0
Drug NDC: 00093-0074-01
Quantity: 20
Days Supply: 20
AWP Cost/Unit: $4.61
Total Drug Cost: $92.20
Dispensing Fee: $2.00
Total Billed: $94.20
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 2
Pharmacy DAW Code: 0
Drug NDC: 00093-0074-01
Quantity: 20
Days Supply: 20
AWP Cost/Unit: $4.61
Total Drug Cost: $92.20
Dispensing Fee: $2.00
Total Billed: $94.20
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 9956633
Dispensing Date: 12/17/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 12/17/20XX
Initials: RPh
Drug Manu: Teva
Rx Documentation
Dispensing Date: 12/17/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 12/17/20XX
Initials: RPh
Drug Manu: Teva
