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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	2953775		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778604	MR00223267	02	02/16/2021	02/16/2021	02/17/2021	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	60	30	50.00000	Replenished		1001811909	987581092
False	2957039		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778604	MR00223267	02	02/16/2021	02/16/2021	02/17/2021	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	60	30	50.00000	Replenished		1001811909	987581092
False	2953780		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779937	MR00248486	00	02/16/2021	02/16/2021	02/17/2021	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	30	30	100.00000	Replenished		1001811909	987581092
False	3110962		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778516	MR00256491	03	03/15/2021	03/15/2021	03/16/2021	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	30	30	100.00000	Replenished		1001826768	3050065356
False	3142213		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780656	MR00223267	00	03/19/2021	03/19/2021	03/20/2021	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	60	30	50.00000	Replenished		1001834470	3051403572
False	3144562		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780656	MR00223267	00	03/19/2021	03/19/2021	03/20/2021	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	60	30	50.00000	Replenished		1001834470	3051403572
False	3166379		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780747	MR00248486	00	03/24/2021	03/24/2021	03/25/2021	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	30	30	100.00000	Replenished		1001831820	3050993427
False	3301294		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778516	MR00256491	04	04/12/2021	04/12/2021	04/13/2021	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	30	30	100.00000	Replenished		1001842172	3052723058
False	3318020		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781239	MR00248486	00	04/14/2021	04/14/2021	04/15/2021	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	60	30	50.00000	Replenished		1001843344	3052979164
False	3322910		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781239	MR00248486	00	04/14/2021	04/14/2021	04/15/2021	68001041504	DULOXETINE HCL DR 60 MG CAP	60 MG	CAPSULE DR	30	60	30	50.00000	Replenished		1001843344	3052979164