Remote Filling Verification - Click on 2 Different Errors
8547102
3/8/20XX
Royal T. Shumway
Royal T. Shumway
For Office Use Only.
Hydrocodone/APAP 7.5 mg/750 mg Tablet
100
0
3/8/20XX
Watson
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 52544-0387-01
Quantity: 100
Days Supply: 10
AWP Cost/Unit: $0.70
Total Drug Cost: $70.00
Dispensing Fee: $2.00
Total Billed: $72.00
Payer Code: CASH
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 52544-0387-01
Quantity: 100
Days Supply: 10
AWP Cost/Unit: $0.70
Total Drug Cost: $70.00
Dispensing Fee: $2.00
Total Billed: $72.00
Payer Code: CASH
Pharmacy Software System
Rx Documentation
Rx Number:
Dispensing Date: 3/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 3/8/20XX
Initials: RPh
Drug Manu: Watson
Rx Documentation
Dispensing Date: 3/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 3/8/20XX
Initials: RPh
Drug Manu: Watson
