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Patient Information

BVL Pharma

Phone 8500632792 Fax 8500632792 Print Dt: 9/20/2018
Rx Pres: PETER TEST
#10 DOENING ST,
IMALY CITY, MI 48444
Phn: 7793941502
FAX: 7793941502
Ord:
NPI#
LIC#: 3333
Prescription Id#: TA12345
Patient:    TEST JOE
DOB: 12/12/1995                   Gender:      M
Address: 1122 TEST AVE     CARO, MI 48723
Phone     9703690858
Signed electronically by: 
Date: 
This Prescription Will be Filled Generically Unless Prescriber Writes "DAW" in the Box
N
Dispense As Written
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