Remote Filling Verification - Click on 2 Different Errors
6492374563
8/4/20XX
Robert Roberts
Carolyn Abman
Insert one suppository at first sign of migraine.
May repeat once in 1 hour, if needed. Max: 2/attack.
Cafergot Suppository
6
1
8/4/20XX
Sandoz
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00078-0033-02
Quantity: 6
Days Supply: 3
AWP Cost/Unit: $7.70
Total Drug Cost: $46.20
Dispensing Fee: $2.00
Total Billed: $48.20
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00078-0033-02
Quantity: 6
Days Supply: 3
AWP Cost/Unit: $7.70
Total Drug Cost: $46.20
Dispensing Fee: $2.00
Total Billed: $48.20
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 6492374563
Dispensing Date: 8/4/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 8/4/20XX
Initials: RPh
Drug Manu: Sandoz
Rx Documentation
Dispensing Date: 8/4/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 8/4/20XX
Initials: RPh
Drug Manu: Sandoz
