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Health Center:

Pharmacy:

Capture Date :

To:

			Health Center	Pharmacy	ShipTo	Claim Type	RX Number	Member ID	Fill	Fill Date	Adjud Date	Captured Date	NDC	Drug Name	Strength	Form	Pkg Size	QTY Disp	Curr QTY	% of Claim	Status	Status Date	Order	Wholesaler Invoice
False	10041571		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	05	07/28/2023	07/28/2023	07/29/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	96	80.00000	Replenished	08/16/2023	1002259761	3143593677
False	10154860		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012820	MR00252736	00	08/14/2023	08/14/2023	08/15/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	56	4	7.14300	Replenished	08/16/2023	1002259761	3143593677
False	9758102		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	04	06/22/2023	06/22/2023	06/23/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	20	16.66700	Replenished	08/22/2023	1002251766	3141657238
False	10036255		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	05	07/28/2023	07/28/2023	07/29/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	24	20.00000	Replenished	08/22/2023	1002251766	3141657238
False	9941707		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012778	MR00252736	00	07/13/2023	07/13/2023	07/14/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	56	56	100.00000	Replenished	08/22/2023	1002251766	3141657238
False	9752338		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	04	06/22/2023	06/22/2023	06/23/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	100	83.33300	Replenished	06/26/2023	1002236912	3137855545
False	9391916		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	03	05/15/2023	05/15/2023	05/16/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	20	16.66700	Replenished	06/16/2023	1002234551	3136912239
False	9391915		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012685	MR00252736	00	05/16/2023	05/16/2023	05/17/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	56	24	42.85700	Replenished	06/16/2023	1002234551	3136912239
False	9672387		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012736	MR00252736	00	06/14/2023	06/14/2023	06/15/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	56	56	100.00000	Replenished	06/16/2023	1002234551	3136912239
False	9133510		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	02	04/14/2023	04/14/2023	04/15/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	12	10.00000	Replenished	05/18/2023	1002221191	3133750054