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Anytime Pharmacy 1234 123 Any Street Home Town US 12345-6789 RX 1234567 1 DOE JANE 456 Home Road Home 509 555-1234 10 Store NPI 1234567890 3 Date Filled 1/1/2009 2 DOB 01/01/1900 509 555-5678 DAW 0 7 500 mg capsules Teva 6 NDC 00000-1111-22 4 QTY 45 5 Days Supply 30 9 COPAY 20. Copay 10. Pharmacy NPI or NABP number 11. Physician name and NPI number Required information 11 Dr. Section 2 Prescription information Date filled mm/dd/yyyy RX number New Refill check one Physician NPI number Vaccine...
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