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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	2976637		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777868	MR00005078	03	02/22/2021	02/22/2021	02/23/2021	00527328346	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	30	30	100.00000	Replenished		1001823796	3049396293
False	3166380		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777868	MR00005078	04	03/24/2021	03/24/2021	03/25/2021	00527328346	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	30	30	100.00000	Replenished		1001839075	3052306186
False	3026238		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778384	MR00086036	03	03/02/2021	03/02/2021	03/03/2021	00527328346	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	30	30	100.00000	Replenished		1001823796	3049396293
False	3426479		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779277	MR00005078	00	04/26/2021	04/26/2021	04/27/2021	00527328346	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	90	90	100.00000	Replenished		1001849254	3054056168
False	4105970		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779277	MR00005078	01	07/22/2021	07/22/2021	07/23/2021	00527328346	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	90	90	100.00000	Replenished		1001892297	3062473633
False	4772151		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779277	MR00005078	02	10/19/2021	10/19/2021	10/20/2021	00527328346	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	90	30	33.33300	Replenished		1001952043	3072719019
False	4766977		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779277	MR00005078	02	10/19/2021	10/19/2021	10/20/2021	00527328346	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	90	60	66.66700	Replenished		1001945703	3071287759
False	3056736		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779321	MR00210929	00	03/08/2021	03/08/2021	03/09/2021	00527328346	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	30	30	100.00000	Replenished		1001823796	3049396293
False	2934441		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779877	MR00198781	00	02/12/2021	02/12/2021	02/13/2021	00527328346	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	90	90	100.00000	Replenished		1001811232	987509358
False	2976605		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780093	MR00319325	00	02/22/2021	02/22/2021	02/23/2021	00527328346	LEVOTHYROXINE 88 MCG TABLET	88 MCG	TABLET	90	90	90	100.00000	Replenished		1001816056	987916714