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Patient

Name
Mr. Maria, Rodriguez
Date of Birth
10/07/1976
Gender
M
Marital Status
Single
Race
Samoan
Relationship
Spouse
MRN
123456789
Phone Number
715 361 4850
Email
[email protected]
Delivery Option
DHL Express
Contact Preference
Email
Auto Refill
Special Restrictions
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Title

Last Name

First Name

Middle Name

Date of Birth

Gender

Marital Status

Height

ft.

in.

Weight

lbs

Race

Relationship

Auto Refill

MRN

Pregnant (Due Date)

Primary Prescriber

Johnson James

DEA: BJ0479292, NPI: 1053370650

Discount

Tax Exempt

Delivery Options

*Address

Address line 2

*City

*State

*ZIP

*Address Type

Primary

Delivery

Type

Number

Ext.

Primary

Add

Email

Primary

Add

Delivery Option

Contact Preference

Social Security

U.S Military ID

Driver’s License

State

Exp.

Special Restrictions

Delivery Option

Contact Preference

Social Security

U.S Military ID

Driver’s License

State

Exp.

Special Restrictions

Prescriber

Name
Mr. John Nathan Turner
Speciality Code
Hospitalist
License Type
NPI
State
AL
License Number
123456789
SPI Number
123456789123456789
*Address
2349 Spinnaker Lane
*City
Joliet
*State
LA
*ZIP
60432
*Address Type
Office
Primary

Prescription

Prescribed Drug
A-200 Maximum Strength Liquid 0.33-4 %
Prescribed On
10/02/2019
Diagnosis
Abdominal actinomycosis

Prescribed Drug

Trial

Pres Qty

Refills

Prescribed

Expires

Opioid

Diagnosis

Dispensed Drug

Fill No 0

Rem Qty 0

Disp Qty

Dispensed

DAW

Tech

RPh

Prod Expires

Origin

Sig

Language

Days Supply

Labels to print

Delivery Option

Process Date/Time

Pickup Date/Time

Product

Product Name
Abacavir Sulfate Tablet 300 MG
NDC
99999-9999-97
GPI
5123478421
Manufacturer
Alpha Drugs
PKG Size
8.823
Generic Name
Metolazone

*NDC/UPC/HRI

*Product Name

Strength

UOM

Vial Label Name

*Product Type

Unit Dose

Manufacturer

Therapy Class

Schedule

Effective Date

Expiration Date

Package Size

UOM

Route

Form

Sig. (i)

Package WAC

04/05/2019 M

Package Acquisition

04/05/2019 M

Package AWP

04/05/2019 M

% of AWP

Calculated Acquisition :

Direct Price

04/05/2019

Price Schedule

Third Party

Payer Name
Medicare DMERC
Abbrev
DMERC
Plan Name
Unit Linked Insurance Plan
PCN
PCN54
Status

*Payer Name

Group Name

*Abbrev (i)

Effective Date (i)

Discountinue Date (i)

*Bin

*Processor Cntl

*Vndr/Cert ID

Plan ID

*Switch

Medicaid

State of

Medicare

Workers Comp

Name Name	Date of Birth Date of Birth	Address Address	City City	State State	ZIP ZIP	Phone Phone	Status Status
Annie Wiedman	10/07/1978	88 Center Rd	Bedford	OH	44146	715-361-4850	Active
Maria Rodriguez	12/03/1976	2349 Spinnaker Lane	Joliet	LA	60432	724-376-4350	Active
Scott Adams	08/19/1979	1919 County Line Road	Tampa	FL	33634	727-729-9038	Active
Smith James	04/11/1978	1566 Elm Drive	Cambridge	NY	12816	532-247-7219	Active
Teresa Andresen	11/28/1987	1227 Perine Street	Alexandria	VA	22304	703-823-4297	Active