Remote Filling Verification - Click on 2 Different Errors
87926434
11/27/20XX
Janet T. Jones
Sandra Jones
Take one tablet by mouth 30 minutes before breakfast every day.
Glipizide 10 mg Tablet
30
11
10/27/20XX
Geneva
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00781-1453-13
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $0.61
Total Drug Cost: $18.30
Dispensing Fee: $2.00
Total Billed: $20.30
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00781-1453-13
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $0.61
Total Drug Cost: $18.30
Dispensing Fee: $2.00
Total Billed: $20.30
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 87926434
Dispensing Date: 11/27/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 11/27/20XX
Initials: RPh
Drug Manu: Geneva
Rx Documentation
Dispensing Date: 11/27/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 11/27/20XX
Initials: RPh
Drug Manu: Geneva
