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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	4018952		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000783206	MR00279837	00	07/09/2021	07/09/2021	07/09/2021	00093354143	ESTRADIOL 0.01% CREAM	0.01 %	CREAM/APPL	42.5	42.5	42.5	100.00000	Replenished		1001888398	3061086532
False	5245430		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000787135	MR00152715	00	12/22/2021	12/22/2021	12/22/2021	00093354143	ESTRADIOL 0.01% CREAM	0.01 %	CREAM/APPL	42.5	42.5	42.5	100.00000	Replenished		1001977713	3078024703
False	6244300		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000790049	MR00240690	00	05/05/2022	05/05/2022	05/05/2022	00093354143	ESTRADIOL 0.01% CREAM	0.01 %	CREAM/APPL	42.5	42.5	42.5	100.00000	Replenished		1002046742	3092154589
False	8581304		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000790049	MR00240690	01	02/14/2023	02/14/2023	02/14/2023	00093354143	ESTRADIOL 0.01% CREAM	0.01 %	CREAM/APPL	42.5	42.5	42.5	100.00000	Replenished		1002178976	3123538684
False	6741171		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791162	MR00250558	00	06/28/2022	06/28/2022	06/29/2022	00093354143	ESTRADIOL 0.01% CREAM	0.01 %	CREAM/APPL	42.5	42.5	42.5	100.00000	Replenished		1002075262	3097972963