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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	9848963		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795715	MR00315442	05	07/03/2023	07/03/2023	07/04/2023	68382009601	HYDROXYCHLOROQUINE 200 MG TAB	200 MG	TABLET	100	30	30	100.00000	Replenished	08/22/2023	1002240777	3139104980
False	9866549		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796462	MR00192351	04	07/05/2023	07/05/2023	07/06/2023	68382009601	HYDROXYCHLOROQUINE 200 MG TAB	200 MG	TABLET	100	60	60	100.00000	Replenished	08/22/2023	1002240777	3139104980
False	9678738		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796897	MR00107755	02	06/14/2023	06/14/2023	06/15/2023	68382009601	HYDROXYCHLOROQUINE 200 MG TAB	200 MG	TABLET	100	60	10	16.66700	Replenished	08/22/2023	1002240777	3139104980
False	9616449		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796462	MR00192351	03	06/07/2023	06/07/2023	06/08/2023	68382009601	HYDROXYCHLOROQUINE 200 MG TAB	200 MG	TABLET	100	60	50	83.33300	Replenished	06/16/2023	1002234551	3136913250
False	9672398		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796897	MR00107755	02	06/14/2023	06/14/2023	06/15/2023	68382009601	HYDROXYCHLOROQUINE 200 MG TAB	200 MG	TABLET	100	60	50	83.33300	Replenished	06/16/2023	1002234551	3136913250
False	9562782		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795715	MR00315442	04	06/01/2023	06/01/2023	06/03/2023	68382009601	HYDROXYCHLOROQUINE 200 MG TAB	200 MG	TABLET	100	30	30	100.00000	Replenished	06/09/2023	1002231800	3136126192
False	9610747		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796462	MR00192351	03	06/07/2023	06/07/2023	06/08/2023	68382009601	HYDROXYCHLOROQUINE 200 MG TAB	200 MG	TABLET	100	60	10	16.66700	Replenished	06/09/2023	1002231800	3136126192
False	9595274		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798421	MR00396692	00	06/06/2023	06/06/2023	06/07/2023	68382009601	HYDROXYCHLOROQUINE 200 MG TAB	200 MG	TABLET	100	60	60	100.00000	Replenished	06/09/2023	1002231800	3136126192
False	9295684		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794477	MR00208636	05	05/02/2023	05/02/2023	05/04/2023	68382009601	HYDROXYCHLOROQUINE 200 MG TAB	200 MG	TABLET	100	60	40	66.66700	Replenished	05/19/2023	1002221549	3133876132
False	9397837		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796462	MR00192351	02	05/09/2023	05/09/2023	05/17/2023	68382009601	HYDROXYCHLOROQUINE 200 MG TAB	200 MG	TABLET	100	60	60	100.00000	Replenished	05/19/2023	1002221549	3133876132