Remote Filling Verification - Click on 2 Different Errors
856358543
9/22/20XX
John Moore
Harold Green
Take one tablet by mouth as needed for chest pain.
Nitrostat 0.3 mg Tablet
100
Prn
8/22/20XX
PD
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00071-0569-24
Quantity: 100
Days Supply: 33
AWP Cost/Unit: $0.20
Total Drug Cost: $6.00
Dispensing Fee: $2.00
Total Billed: $8.00
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00071-0569-24
Quantity: 100
Days Supply: 33
AWP Cost/Unit: $0.20
Total Drug Cost: $6.00
Dispensing Fee: $2.00
Total Billed: $8.00
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 856358543
Dispensing Date: 9/22/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 9/22/20XX
Initials: RPh
Drug Manu: PD
Rx Documentation
Dispensing Date: 9/22/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 9/22/20XX
Initials: RPh
Drug Manu: PD
