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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	10080805		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799533	MR00043501	00	08/04/2023	08/04/2023	08/05/2023	00591534701	PROBENECID 500 MG TABLET	500 MG	TABLET	100	60	40	66.66700	Replenished	08/22/2023	1002253366	3142468423
False	9873269		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798994	MR00043501	00	07/06/2023	07/06/2023	07/07/2023	00591534701	PROBENECID 500 MG TABLET	500 MG	TABLET	100	60	60	100.00000	Replenished	08/22/2023	1002253366	3142468423
False	9595275		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798407	MR00043501	00	06/06/2023	06/06/2023	06/07/2023	00591534701	PROBENECID 500 MG TABLET	500 MG	TABLET	100	60	60	100.00000	Replenished	06/08/2023	1002227496	3135977002
False	9276438		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797116	MR00043501	01	05/02/2023	05/02/2023	05/04/2023	00591534701	PROBENECID 500 MG TABLET	500 MG	TABLET	100	60	20	33.33300	Replenished	05/08/2023	1002213418	3132524753
False	9295611		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797116	MR00043501	01	05/02/2023	05/02/2023	05/04/2023	00591534701	PROBENECID 500 MG TABLET	500 MG	TABLET	100	60	40	66.66700	Replenished	06/08/2023	1002227496	3135977002
False	9035410		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797116	MR00043501	00	04/04/2023	04/04/2023	04/05/2023	00591534701	PROBENECID 500 MG TABLET	500 MG	TABLET	100	60	60	100.00000	Replenished	05/08/2023	1002213418	3132524753
False	8771329		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795882	MR00043501	01	03/06/2023	03/06/2023	03/07/2023	00591534701	PROBENECID 500 MG TABLET	500 MG	TABLET	100	60	20	33.33300	Replenished	05/08/2023	1002213418	3132524753
False	8765205		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795882	MR00043501	01	03/06/2023	03/06/2023	03/07/2023	00591534701	PROBENECID 500 MG TABLET	500 MG	TABLET	100	60	40	66.66700	Replenished		1002185583	3125815325
False	8485457		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795882	MR00043501	00	02/03/2023	02/03/2023	02/04/2023	00591534701	PROBENECID 500 MG TABLET	500 MG	TABLET	100	60	60	100.00000	Replenished		1002185583	3125815325
False	8187314		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794587	MR00043501	01	12/30/2022	12/30/2022	01/01/2023	00591534701	PROBENECID 500 MG TABLET	500 MG	TABLET	100	60	60	100.00000	Replenished		1002155556	3118088750