Provider Name: __Brandie Ingram_____________
Superhero Family Practice, INC
1234 Kryptonite Way
Superhero City, Superhero State 12301
(800) 123-4567
Patient Name: __Louis Brown______________________ Date: __09/12/2020__________
Address: ___9056 Eagle Park Road, Atlanta, GA 30302______ DOB: 10/12/1975____
License: _RN230125__ NPI: _1832217629__ DEA ( Controlled Substances Only): ______________
Levetiracetam 750 mg tablets
Sig: take 2 tablets twice daily by mouth
Disp#: 360
1 Refill
DISPENSE AS WRITTEN (DAW) Generic Substitution Permitted
Brandie Ingram
Signature of Provider Signature of Provider
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