PRESCRIPTION TRANSFER TO YOUR PHARMACY

A patient (or a person authorized to act on a patient’s behalf) asked us

to transfer the Rx on page 2 from our pharmacy to your pharmacy
for processing and dispensing.

Thank you for assisting our mutual patient with this transfer.

To speak with the dispensing pharmacist to verify this transfer or for any other reason,
please contact us at 314-632-6172.

Total transmission 3 pages including this cover page.

MedsByMe, Inc.
1228 Birch Meadow Court
St. Louis, MO 63049
MO License #2017036904
pharmacist@medsbyme.com
314-632-6172 tel
888-783-0433 fax

Page 1 of 4
Confidentiality Notice: This message contains protected health information (PHI) and has been sent for
the sole use of the intended recipient(s). If the reader of this message is not the intended recipient, you
are hereby notified that any unauthorized review, use, disclosure, dissemination, distribution or copying
of this email and message and/or attachments is strictly prohibited. If you have received this
transmission in error, please notify the sender by calling 314-632-6172 and destroy all copies of this.

Patient Information:

NAME Gupta Abhishek

BIRTHDATE 25/09/2017
SEX M
ADDRESS somewhere in the US, New York, 10014
PHONE 1 998-877-6657
PHONE 2
PHONE 3
EMAIL abhishek.gupta@tactionsoftware.com

Prescription:

RX # 7088342044
DRUG DESCRIPTION DOLOGESIC-DF 500MG-1MG TABLET
STRENGTH 500MG-1MG
FORM TABLET
QUANTITY PRESCRIBED 30
DIRECTIONS test
COMMENTS
DAW 0
PRESCRIBER test
ADDRESS 400 Pelham Pkwy S Bronx, NY 10461

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PHONE 998-877-6655
FAX
NPI 4322112233
DEA
STATE LIC
SUPERVISOR NAME
SUPERVISOR NPI
SUPERVISOR DEA
SUPERVISOR STATE LIC
DATE WRITTEN 19/12/2017
FIRST FILL DATE
MOST RECENT FILL DATE 12/12/2017
REFILLS 5 REFILL TRANSFERRED, 35 REFILLS REMAIN

Additional patient information is on the following page.

Insurance Information

RxBIN
RxPCN
RxGROUP
MEMBER ID

Transferring Pharmacy

NAME Walgreen Eastern Co Inc

ADDRESS 2095 Dutch Broadway, NY 11003
PHONE 516-285-4080
FAX 217-709-2344
PHARMACIST

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Patient Medical Information

PREGNANT
BREASTFEEDING
ALLERGIES none
MEDICAL CONDITIONS none

Patient’s Recent Medication Fills (including as self-reported by patient):

Medication Name Strength Amount Instructions Last Fill Date

DOLOGESIC-DF 500MG-1MG #30.00 test 10/01/2019
DOLOGEN 650 MG-2MG #30.00 27/12/2018

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