Remote Filling Verification - Click on 2 Different Errors
7301456
4/22/20XX
Stanley M. Bontrager
Norman Keyes
Take one or two tablets by mouth every 4 hours as needed to
prevent opioid withdrawal symptoms.
Roxicodone 5 mg Tablet
50
0
4/22/20XX
Roxane
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00054-4657-25
Quantity: 50
Days Supply: 4
AWP Cost/Unit: $0.34
Total Drug Cost: $17.00
Dispensing Fee: $2.00
Total Billed: $19.00
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00054-4657-25
Quantity: 50
Days Supply: 4
AWP Cost/Unit: $0.34
Total Drug Cost: $17.00
Dispensing Fee: $2.00
Total Billed: $19.00
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 7301456
Dispensing Date: 4/22/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 4/22/20XX
Initials: RPh
Drug Manu:
Rx Documentation
Dispensing Date: 4/22/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 4/22/20XX
Initials: RPh
Drug Manu:
