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Customer number: 21322Int Date: 2/16/2007
<br />Store number: 16639 mil—mrtteed hone: (916) 928-0641
<br />Batch number: 153 ertstrra Wholesaler: AMERISOURCEBERGEN-008
<br />Account number: 008-030510 Address: 1325 WEST STRIKER AVENUE
<br />Name: DEUEL VOCATIONAL SACRAMENTO, CA 95834
<br />INSTITUTION
<br />Credits passed through: 21322
<br />Customer reference number: GRX21322153
<br />Service Date: 01/2272007
<br />Non -Returnable Report
<br />TEVA PHARM.
<br />>'.",, s rifNe:.ilie.,r:,.n':.'r:;,'; ,�Quar%t(ty, ,,,,,Sf,.sB,,,,, Strength.;.t,.«;,...NPC••.NP„ Class ,.;iPrice_:,...,., iCoda,
<br />RIBAVIRIN 0.11984.00 200 MG 93722758 R 59.58 02 R12012
<br />Total 1 14.0001 1 724.77
<br />11MIT;zn RFCFARr:I-1
<br />Drug Na}ne .' �.
<br />Quanfity:
<br />1:1'1' ze": -
<br />S2rangth
<br />` , NDG lD a ": '
<br />ass
<br />. Piiaa ;1:"
<br />RGade
<br />LotNu{nber' ,"
<br />Expire ate s
<br />THIORIDAZINE HCL
<br />0.300
<br />100.00
<br />50 MG
<br />00677082501
<br />R
<br />7.77
<br />02
<br />49033
<br />METHENAMINE MANDELATE
<br />0.300
<br />100.00
<br />iGM
<br />00677168201
<br />R
<br />8.33
<br />02
<br />3635A1
<br />SULFASALAZINE
<br />0.200
<br />100.00
<br />500 MG
<br />00677048301
<br />R
<br />2.09
<br />02
<br />53183
<br />Total:
<br />3.000
<br />18.19
<br />UPSHER-SMITH
<br />.' ., Drug Name-, ,..,,-:
<br />., "`
<br />Quantity °'.SIz:;- Strength ,,
<br />NOCNQ= _ Class-`„Prloe..: RCode '.; LatNumbar,-„-",.,' LxplreDate'.
<br />CHLORPROMAZINE HCL
<br />00303758 09/06
<br />0.200 100.00 200 MG
<br />00832030400 R 10.48 05 210 it9
<br />Total:
<br />1.000
<br />10.48
<br />VALEANT PHARMACEUTIC
<br />"Drug Name ' Quantity„ ; 9lze "- - 9erength ; �,' NDCNO ,,, ,`3 IIlass Rrlae. RGade Lot Number, )EX raLtaw,
<br />EFUDEX 1.000 1.00 5% 00187320426 R 92.74 01 CO200 12/05
<br />Total: 1.000 92.74
<br />VERSAPHARM
<br />t:. Drug Hama . 'Quawlty, ..., ; Si;'e, ; -, ,.Strength, --
<br />:J NDCNO ,' .Glass , ;price ��; -1�Cotle
<br />� _ =lot Ngmbar r,., fir: , Expjre Pate;
<br />PYRAZINAMIDE 1.000 60.00 500 MG
<br />61748001206 1 R I55.80 01
<br />00303758 09/06
<br />Total: 1.0001 1
<br />1 1 55.80
<br />WATSON PHARMA. INC.
<br />,; Drug Name , Quar
<br />BACLOFEN
<br />0.200
<br />Total: 2,000
<br />.00 20 MG 00591544301 R 1 1.39 05 PO4GO293
<br />54.83
<br />Reason Code:
<br />01 OUTDATED PAST VENDOR POLICY
<br />02 VENDOR ACCEPTS FULL PACKAGES ONLY 04 OUTSIDE VENDOR POLICY
<br />05 UNDER MINIMUM QUANTITY
<br />06 WHSLR RTN. NO CHARGE 19 DAMAGED DURING SHIPPING
<br />20 VENDOR DOES NOT ACCEPT PRESCRIPTIONS
<br />21 VENDOR DOES NOT ISSUE CREDIT FOR THIS PRODUCT
<br />NY Division: 100 Colin Drive, Holbrook, NY 11741, Phone: 1-800-473-2138, Midwest Division: 100 Teduke Court, St Charles, MO 63301, Phone: 1-800-729-3279
<br />Page 9 of 11
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