(1) Each entity registered by the board as a certified pharmacy or as an out-of-state mail service pharmacy that dispenses to patients in Montana shall provide the following controlled substances dispensing information to the board:

(a) pharmacy name, address, telephone number, and drug enforcement administration number;

(b) full name, address, telephone number, gender, and date of birth for whom the prescription was written;

(c) full name, address, telephone number, and drug enforcement administration registration number of the prescriber;

(d) date the prescription was issued by the prescriber;

(e) date the prescription was filled by the pharmacy;

(f) indication of whether the prescription dispensed is new or a refill;

(g) name, national drug code number, strength, quantity, dosage form, and days' supply of the actual drug dispensed;

(h) prescription number assigned to the prescription order; and

(i) source of payment for the prescription that indicates one of the following:

(i) cash;

(ii) insurance; or

(iii) government subsidy.