Remote Filling Verification - Click on 2 Different Errors
7645987
3/13/20XX
Mary F. Mott
James T. Warren
Apply a thin layer to the affected area two times daily.
Fluocinonide 0.05% Topical Ointment
30 g
1
3/13/20XX
Fougera
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00168-0140-30
Quantity: 30 g
Days Supply: 14
AWP Cost/Unit: $0.98
Total Drug Cost: $29.40
Dispensing Fee: $2.00
Total Billed: $31.40
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00168-0140-30
Quantity: 30 g
Days Supply: 14
AWP Cost/Unit: $0.98
Total Drug Cost: $29.40
Dispensing Fee: $2.00
Total Billed: $31.40
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 7645987
Dispensing Date: 3/13/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 3/13/20XX
Initials: RPh
Drug Manu: Fougera
Rx Documentation
Dispensing Date: 3/13/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 3/13/20XX
Initials: RPh
Drug Manu: Fougera
