Remote Filling Verification - Click on 2 Different Errors
873520912
11/26/20XX
Mary S. Wright
Samuel Bernstein
Administer two sprays into each nostril daily.
Flonase 0.05% Nasal Spray
32 g
6
10/26/20XX
A%26H
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00173-0453-01
Quantity: 32 g
Days Supply: 30
AWP Cost/Unit: $6.39
Total Drug Cost: $204.48
Dispensing Fee: $2.00
Total Billed: $206.48
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00173-0453-01
Quantity: 32 g
Days Supply: 30
AWP Cost/Unit: $6.39
Total Drug Cost: $204.48
Dispensing Fee: $2.00
Total Billed: $206.48
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 873520912
Dispensing Date: 11/26/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 11/26/20XX
Initials: RPh
Drug Manu: A and H
Rx Documentation
Dispensing Date: 11/26/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 11/26/20XX
Initials: RPh
Drug Manu: A and H
