1. Patient Information: Patient Detail:
Date: 03/04/2013 Doctor: Dr. Calvin Poole, Md
Name: William D Suval Consultant: Doug Flynn
License: a6428881 ca Gender: Male
Social: 0 DOB: 06/27/1949
Allergies: Email: rickyrelish@yahoo.com
Address: 14190 Riverside Dr
City/St/Zip: Apple Valley, CA, USA, 92307
Phone: 760-646-5878
Billing Info: Shipping Info:
Name: William D Suval Name: William D Suval
Address: 14190 Riverside Dr Address: 15030 7th St
City/St/Zip: Apple Valley, CA, USA, 92307 City/St/Zip: Victorville, CA, USA, 92395
Qty Products Total W
1 Ground Shipping (3 Day)
20 Anastrazole 0.5mg
20 Tamoxifen 20mg
SHIP INST.:
TOTAL $225.00