Remote Filling Verification - Click on 2 Different Errors
3409543
2/6/20XX
Coleen L. Bontrager
Sandra Johnson
Take one capsule by mouth two times daily as directed.
Acyclovir 400 mg Tablet
60
2
1/6/20XX
Mylan
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00378-1464-01
Quantity: 60
Days Supply: 30
AWP Cost/Unit: $2.17
Total Drug Cost: $130.20
Dispensing Fee: $2.00
Total Billed: $132.20
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00378-1464-01
Quantity: 60
Days Supply: 30
AWP Cost/Unit: $2.17
Total Drug Cost: $130.20
Dispensing Fee: $2.00
Total Billed: $132.20
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 3409543
Dispensing Date: 2/6/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/6/20XX
Initials: RPh
Drug Manu: Mylan
Rx Documentation
Dispensing Date: 2/6/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/6/20XX
Initials: RPh
Drug Manu: Mylan
