Remote Filling Verification - Click on 2 Different Errors
97562398
8/10/20XX
Sylvia Jones
Norman Keyes
Apply sparingly to affected area two times daily for two
weeks.
Cutivate 0.005% Ointment
30 g
1
8/8/20XX
Glaxo
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00173-0431-00
Quantity: 30 g
Days Supply: 14
AWP Cost/Unit: $1.83
Total Drug Cost: $1.83
Dispensing Fee: $2.00
Total Billed: $3.83
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00173-0431-00
Quantity: 30 g
Days Supply: 14
AWP Cost/Unit: $1.83
Total Drug Cost: $1.83
Dispensing Fee: $2.00
Total Billed: $3.83
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 97562398
Dispensing Date: 8/10/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 8/10/20XX
Initials: RPh
Drug Manu: Glaxo
Rx Documentation
Dispensing Date: 8/10/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 8/10/20XX
Initials: RPh
Drug Manu: Glaxo
