Remote Filling Verification - Click on 2 Different Errors
871230756
7/28/20XX
Stan Bontrager
Carolyn Abman
Apply to affected area three times daily.
Hydrocortisone 0.5% Ointment
28.35 g
0
7/23/20XX
Fougera
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00168-0146-30
Quantity: 28.35 g
Days Supply: 14
AWP Cost/Unit: $0.39
Total Drug Cost: $11.06
Dispensing Fee: $2.00
Total Billed: $13.06
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00168-0146-30
Quantity: 28.35 g
Days Supply: 14
AWP Cost/Unit: $0.39
Total Drug Cost: $11.06
Dispensing Fee: $2.00
Total Billed: $13.06
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 871230756
Dispensing Date: 7/23/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 7/28/20XX
Initials: RPh
Drug Manu: Fougera
Rx Documentation
Dispensing Date: 7/23/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 7/28/20XX
Initials: RPh
Drug Manu: Fougera
