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Indicate the metric quantity expressed in number of tablets grams or milliliters for each ingredient NDC. Indicate the cost for EACH ingredient dollar amount. Indicate the TOTAL compounded quantity. Rx 11-digit NDC Ingredient Name Total Metric Quantity Total Amount Paid by Patient 106-24477a 031412. I certify that I or my eligible dependent have received the medicine described herein. I certify that I have read and understood this form and that all the information entered on this form is true...
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