Shields Pharmacy Prescription Receipt 06/21/2024

SHIELDS PHARMACY 2196 Main St., Dunedin, FL 34698 PH: 727-648-2680 TOLL FREE: 877-867-1658 Shields Pharmacy 2196 Main Street Suite A Dunedin, FL 34698 727-648-2680 FEED THIS DIRECTION Signature Log Signature 06/21/2024 PAYMENT Tx/Invoice #: 68807601 Purchase Order #: Practice Phone: (630) 995-4242 Bill to: SOPHIA JONGSMA 00 Dunedin, FL 33704 (727) 225-2475 Ordering Physician: USL Ship to: SOPHIA JONGSMA 00 Dunedin, FL 34698 (727) 225-2475 Sale Status: This transaction has been approved. Master Order: 56201779 Order Date Description Item Count Price/ Item Discount/ Item Amount 06/20/24 RX 60219773 METHYLCOBALAMIN INJECTION 10MG/ML (5ML VIAL) (Qty: 1 VIAL) (Formula ID: 12063) (Fill ID: 5164188) 1 $ 109.00 $ 109.00 3 Injection Kit 3 $ 5.00 $ 15.00 TOTAL CHARGES $ 124.00 MasterCard 2208 - TX Ref. Number: 80500189176 ($ 124.00) TOTAL CREDITS $ 124.00 TOTAL CHANGE/CREDIT $ 0.00 Please Note: Compounded prescriptions are made specially for you and cannot be returned. SHIELDS PHARMACY SHIELDS PHARMACY 2196 Main St., Dunedin, FL 34698 PH: 727-648-2680 TOLL FREE: 877-867-1658 Receipt SHIELDS PHARMACY 2196 Main St., Dunedin, FL 34698 PH: 727-648-2680 TOLL FREE: 877-867-1658 Receipt