PATIENT INFORMATION PT#: 00100050
Name:
TEST, PATIENT
DOB:
02/01/1970
Gender:
Female
Address 1:
2505 S. FINLEY RD.
Primary Phone:
985-647-1235
Language:
English
City/State/ZIP:
LOMBARD, IL 60148
Secondary Phone:
Member No:
CC000000000
Comment:
Sensitivities:
ASPIRIN
BENZOYL PEROXIDE
CIMETIDINE
COUMARIN ANTICOAGULANTS
+
Health States:
ASTHMA
ANEMIA
ICD Codes:
ASTHMA
OTHER MEDICATIONS
#
Status
Product Name
NDC
Effective
Expiration
Created
Modified
1
Active
BAND AID MIS 1"
08137-0046-51
03/11/2009
03/11/2009
01/19/2001 RRB
03/25/2009 TAL
2
Active
Inactive
ALBUMIN TES REAGENT
00193-3443-24
03/11/2009
03/11/2009
01/19/2001 RRB
04/01/2009 TAL
3
Active
AA&C TAB 400-30MG
00000-0000-00
03/15/2009
03/15/2009
01/19/2001 RRB
#
Label Name/NDC
*
Effective Date
End Date
1
BAND AID MIS 1"
3
SELECT DRUG
#
Prod Name
Pkg Size
Mfr
QoH
AWP
NDC
Stat
1
AA&C TAB 400-30MG
100ea
PERRIGO
1.83
58948-0415-78
2
PAIN RELIEF TAB ADULT
100ea
AMER PHA
1.60
84-0436-01
.Sub
3
ASPIRIN PLUS TAB 400-30MG
100ea
WALGREEN
1.71
363-0415-10
.Sub
4
ASA/CAFF TAB 400-30MG
100ea
CENTURY
1.56
436-0953-01
#
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E
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S No
Document
1
Other Medications
2
Add Medication
3
Change Medication
Close
Inactivate this Other Medication?
Y
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N
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A
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C#
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IN#
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E
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