Provider Name: __Carmen R Jasso__
Superhero Family Practice, INC
1234 Kryptonite Way
Superhero City, Superhero State 12301
(800) 123-4567
Patient Name: __Tameka Johnson____ Date: 11/04/2019
Address: _7490 Highland Oak Drive, Dayton, OH 45066. DOB: 6/1/2017
License: 05312 NPI 1761332500 DEA ( Controlled Substances Only): ______________
Amoxicillin 250mg/5mL suspension
Sig: take 8mL (400mg) by mouth every 12 hours for 10 days
Disp: 80mL 0 refills
DISPENSE AS WRITTEN (DAW) Generic Substitution Permitted
Carmen R Jasso
Signature of Provider Signature of Provider
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