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Get 4fi 18058

T include the following: NABP number or the current name and complete address of pharmacy Full name of the patient Date filled Name of drug, strength (e.g., 500 mg) and dosage form (e.g., capsules, liquid or cream) Prescription number Quantity Charge for each prescription 5. DAYS SUPPLY must be included on the claim form. Calculate your days supply like this: QUANTITY DOSAGE DAYS SUPPLY QUANTITY - Total number of units (pills, tablets, capsules) DIVIDED BY.

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