info

Created By/On:Devel# 11/26/2015 | 5:23:47 AM

Maintained By/On: Jayden Smith 02/12/2018 | 5:06:479 AM

Dispensing

Patient Profile
Doe, John
Age: 36
Date of Birth: 10/07/1976
MRN: 7320524611
A/R Total Balance: $0.00
Diseases:Typhoid/Paratyphoid Fev
Allergies: Abilify
New Commercial Plan, Primary Plan, Doe John
Avia Corporate Plan, Secondary Plan, Doe John
Nimbus Prima Plan, Tertiary Plan, Doe John
Prescribers
Prescriber
James, Smith
4023 Freshour Circle
Phone: 972-608-0265
Ext.:
DEA: BJ0479293
NPI: 1053370650
Fill Options
Delivery Option
Pickup Date/Time
Process Date/Time
Patient Notes
Patient is diagnosed with hyper tension.
06/11/2017
Reported alergy with anitibiotic over 500 mg dose.
06/05/2018
Requested only to dispense generic drug, please check before dispensing.
02/06/2018
Patient Groups: Pain Management
Special Restrictions: Avoid despense non steriod medicines.
Rx Notes
Partial drugs have been dispensed, will notify patient once we receive the stock.
Dispensed Product Info
Name: A/G Pro Tablet
Generic: *Nutritional Supplement Tabs**
Mfg: MILLER
WAC: 11.50 6/16/2015 S
Pack/Sz: 180.000
AAC: 10.20
Unit: EA
DIR: 0.00
AWP %:
AWP:13.80 9/22/2015 S
QOH: 495.000
Cost:
Pricing
Retail:
Reason:
Discount:
Tax:
$5.00
Total:
$6.53
U & C:$6.53
Cost:
$0.28
Price Schedule Used
Profit:
$1.25
Payment Mode
Submitted Total:
Patient Copay:
Last Patient Pay: $6.53
Last Filled Date: 08/23/2017
Total Claims:
Pro Cd\Acct ID: Doe, John