Promethazine Rx.docx - NR565 Prescription Template Provider Name Savannah Ross Superhero Family Practice INC 1234 Kryptonite Way Superhero City

Promethazine Rx.docx - NR565 Prescription Template Provider...

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NR565 Prescription Template Provider Name: Savannah Ross Superhero Family Practice, INC 1234 Kryptonite Way Superhero City, Superhero State 12301 (800) 123-4567 Patient Name: Jamie Sands Date:10/18/2020 Address: 2220 SW 34 Street, Edison, NJ 12345 DOB:10/12/1997 License: 26NJ00289751 NPI: 18269910 DEA (

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