FPV Practice Exam 1-02
5218387
2/11/20XX
Edward Miller
Cynthia McDonald
Take 1 tablet by mouth once daily.
Synthroid 1.25 mg Tablets
30
0
2/11/20XX
Knoll
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00048-1130-03
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $0.49
Total Drug Cost: $14.70
Dispensing Fee: $2.00
Total Billed: $16.70
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00048-1130-03
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $0.49
Total Drug Cost: $14.70
Dispensing Fee: $2.00
Total Billed: $16.70
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 5218387
Dispensing Date: 2/11/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/11/20XX
Initials: RPh
Drug Manu: Knoll
Rx Documentation
Dispensing Date: 2/11/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/11/20XX
Initials: RPh
Drug Manu: Knoll