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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	10218094		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799876	MR00373597	00	08/22/2023	08/22/2023	08/23/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	78	86.66700	Replenished	08/24/2023	1002262221	3144548022
False	10118237		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799657	MR00331064	00	08/10/2023	08/10/2023	08/11/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	28	31.11100	Replenished	08/14/2023	1002254688	3143269122
False	10123682		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799657	MR00331064	00	08/10/2023	08/10/2023	08/11/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	62	68.88900	Replenished	08/21/2023	1002260563	3144082982
False	10100387		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799563	MR00234113	00	08/07/2023	08/07/2023	08/08/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	180	10	5.55600	Replenished	08/10/2023	1002254151	3142973963
False	10107406		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799563	MR00234113	00	08/07/2023	08/07/2023	08/08/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	180	72	40.00000	Replenished	08/14/2023	1002254688	3143269122
False	10107405		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799563	MR00234113	00	08/07/2023	08/07/2023	08/08/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	180	98	54.44400	Replenished	08/10/2023	1002254151	3142973963
False	10056549		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799484	MR00182534	00	08/01/2023	08/01/2023	08/02/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	60	18	30.00000	Replenished	08/22/2023	1002252535	3142130208
False	10062946		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799484	MR00182534	00	08/01/2023	08/01/2023	08/02/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	60	42	70.00000	Replenished	08/10/2023	1002254151	3142973963
False	10000389		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799274	MR00178696	00	07/21/2023	07/21/2023	07/22/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	22	24.44400	Replenished	08/22/2023	1002250380	3141162969
False	9996078		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799274	MR00178696	00	07/21/2023	07/21/2023	07/22/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	68	75.55600	Replenished	08/22/2023	1002249643	3140846559