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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	9873262		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792895	MR00392755	10	07/06/2023	07/06/2023	07/07/2023	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	28	28	100.00000	Replenished	08/22/2023	1002248399	3140374263
False	9972261		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794463	MR00263084	02	07/19/2023	07/19/2023	07/20/2023	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	84	56	66.66700	Replenished	08/22/2023	1002248829	3140665212
False	9960603		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799167	MR00239553	00	07/17/2023	07/17/2023	07/18/2023	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	84	28	33.33300	Replenished	08/22/2023	1002248829	3140665212
False	9957998		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799167	MR00239553	00	07/17/2023	07/17/2023	07/18/2023	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	84	56	66.66700	Replenished	08/22/2023	1002248399	3140374263
False	9129110		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792895	MR00392755	07	04/14/2023	04/14/2023	04/15/2023	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	28	28	100.00000	Replenished	06/14/2023	1002233505	3136619883
False	9375406		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792895	MR00392755	08	05/15/2023	05/15/2023	05/16/2023	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	28	28	100.00000	Replenished	06/14/2023	1002233505	3136619883
False	9653364		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792895	MR00392755	09	06/12/2023	06/12/2023	06/13/2023	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	28	28	100.00000	Replenished	06/14/2023	1002233505	3136619883
False	9115844		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794463	MR00263084	01	04/13/2023	04/13/2023	04/14/2023	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	84	84	100.00000	Replenished	04/17/2023	1002207066	3130202878
False	2934117		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000772327	MR00227585	04	01/14/2021	01/14/2021	01/15/2021	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	84	28	33.33300	Replenished		1001816056	987916714
False	2934116		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000772327	MR00227585	04	01/14/2021	01/14/2021	01/15/2021	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	84	56	66.66700	Replenished		1001796904