FPV Practice Exam 1-06
99494053
2/8/20XX
Betty Moore
George Platz
Take 1 tablet by mouth once daily.
Furosemide 40 mg Tablets
100
1
2/8/20XX
Roxane
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 63304-0625-10
Quantity: 100
Days Supply: 100
AWP Cost/Unit: $0.16
Total Drug Cost: $16.00
Dispensing Fee: $2.00
Total Billed: $18.00
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 63304-0625-10
Quantity: 100
Days Supply: 100
AWP Cost/Unit: $0.16
Total Drug Cost: $16.00
Dispensing Fee: $2.00
Total Billed: $18.00
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 99494053
Dispensing Date: 2/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/8/20XX
Initials: RPh
Drug Manu: Ranbaxy
Rx Documentation
Dispensing Date: 2/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/8/20XX
Initials: RPh
Drug Manu: Ranbaxy