FPV Practice Exam 2-10
1060177
2/8/20XX
Julie Bontrager
Royal T. Shumway
Take 1 teaspoonful (5 mL) by mouth 3 times a day until all is taken.
Polycillin 250 mg/5 mL Oral Suspension
100 mL
0
2/7/20XX
Bristol
1 Year
RPh
Pharmacy Software System
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00015-7998-40
Quantity: 100 mL
Days Supply: 7
AWP Cost/Unit: $0.05
Total Drug Cost: $5.00
Dispensing Fee: $2.00
Total Billed: $7.00
Payer Code: 3-PARTY
Insurance Information
Rx Origin Code: 1
Pharmacy DAW Code: 0
Drug NDC: 00015-7998-40
Quantity: 100 mL
Days Supply: 7
AWP Cost/Unit: $0.05
Total Drug Cost: $5.00
Dispensing Fee: $2.00
Total Billed: $7.00
Payer Code: 3-PARTY
Pharmacy Software System
Rx Documentation
Rx Number: 1060177
Dispensing Date: 2/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/8/20XX
Initials: RPh
Drug Manu: Bristol
Rx Documentation
Dispensing Date: 2/8/20XX
Fill Type: New
Fill Number: 1
Last Fill Date: 2/8/20XX
Initials: RPh
Drug Manu: Bristol