FPV Practice Exam 2-02
73335576
3/14/20XX
Edward Miller
Cynthia McDonald
Take 1 tablet by mouth once daily.
Synthroid 3 mg Tablets
30
0
3/14/20XX
Knoll
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00048-1170-03
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $0.82
Total Drug Cost: $24.60
Dispensing Fee: $2.00
Total Billed: $26.60
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 1
Drug NDC: 00048-1170-03
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $0.82
Total Drug Cost: $24.60
Dispensing Fee: $2.00
Total Billed: $26.60
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 73335576
Dispensing Date: 3/14/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 3/14/20XX
Initials: RPh
Drug Manu: Knoll
Rx Documentation
Dispensing Date: 3/14/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 3/14/20XX
Initials: RPh
Drug Manu: Knoll