FPV Practice Exam 2-03
71501628
4/22/20XX
Kyle Bruno
James Warner
Take 1 tablet by mouth once daily at bedtime.
Amitriptyline 100 mg Tablets
30
3
4/22/20XX
Mylan
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00378-2685-93
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $1.11
Total Drug Cost: $33.30
Dispensing Fee: $2.00
Total Billed: $35.30
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00378-2685-93
Quantity: 30
Days Supply: 30
AWP Cost/Unit: $1.11
Total Drug Cost: $33.30
Dispensing Fee: $2.00
Total Billed: $35.30
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 71501628
Dispensing Date: 4/22/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 4/22/20XX
Initials:
Drug Manu: Mylan
Rx Documentation
Dispensing Date: 4/22/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 4/22/20XX
Initials:
Drug Manu: Mylan