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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	2934483		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011062	MR00076060	00	11/16/2020	11/16/2020	11/17/2020	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	30	25	83.33300	Replenished		1001765592
False	8539790		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012410	MR00170923	01	02/09/2023	02/09/2023	02/10/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	45	19	42.22200	Replenished		1002178117	3123055056
False	8535443		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012410	MR00170923	01	02/09/2023	02/09/2023	02/10/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	45	26	57.77800	Replenished		1002177591	3123055052
False	8890555		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012410	MR00170923	02	03/20/2023	03/20/2023	03/21/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	45	13	28.88900	Replenished		1002197595	3128646477
False	8885308		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012410	MR00170923	02	03/20/2023	03/20/2023	03/21/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	45	32	71.11100	Replenished		1002193992	3127402542
False	8367489		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012456	MR00192351	02	01/20/2023	01/20/2023	01/21/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	30	30	100.00000	Replenished		1002167937	3121218015
False	8590189		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012456	MR00192351	03	02/15/2023	02/15/2023	02/16/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	30	30	100.00000	Replenished		1002181297	3124504730
False	8859114		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012456	MR00192351	04	03/17/2023	03/17/2023	03/18/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	30	30	100.00000	Replenished		1002193214	3127091766
False	9129116		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012456	MR00192351	05	04/14/2023	04/14/2023	04/15/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	30	30	100.00000	Replenished	04/19/2023	1002208692	3130511069
False	8161964		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012500	MR00062075	00	12/27/2022	12/27/2022	12/28/2022	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	120	10	8.33300	Replenished		1002154521	3117768445