Prescription note
prescription note
Morgan Stanley Children’s Hospital
3959 Broadway, New York, NY 10032
Medicaid Provider #:
00555555
Phone #:
(212) 555-5555
Date:
08/09/2010
NPI #:
5555555555.
Prescribing Physician:
Dr. Jane Doe
LIC:
NY LIC 555555
DEA #:
XYZ5555555
Name:
Juanito Gomez
DOB:
3/19/2007
Home Ph. #:
Address:
1325 Pembroke Road
City:
New York
State:
NY
Zipcode:
10024
Antibiotic 400 mg/5mL
Take 600 mg po bid for 10 days.
Disp: 250
Refills: 0
Take 600 mg po bid for 10 days.
Disp: 250
Refills: 0
Label in Spanish
Sign: