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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	2933815		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776817	MR00316314	01	11/12/2020	11/12/2020	11/13/2020	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001811232	987509358
False	2933814		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776817	MR00316314	02	02/01/2021	02/01/2021	02/02/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001811232	987509358
False	3020616		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776817	MR00316314	03	03/01/2021	03/01/2021	03/02/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001835626	3051655272
False	2933813		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779884	MR00389011	00	02/12/2021	02/12/2021	02/13/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001811232	987509358
False	3048376		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779884	MR00389011	01	03/05/2021	03/05/2021	03/06/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001835626	3051655272
False	3020595		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780252	MR00109185	00	03/01/2021	03/01/2021	03/02/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	90	100.00000	Replenished		1001819373	988099025
False	3231321		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780904	MR00316314	00	03/31/2021	03/31/2021	04/01/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001835626	3051655272
False	3301305		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781168	MR00389011	00	04/12/2021	04/12/2021	04/13/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001859387	3055792361
False	3558513		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781168	MR00389011	01	05/14/2021	05/14/2021	05/15/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001859387	3055792361
False	3470762		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781652	MR00316314	00	05/03/2021	05/03/2021	05/04/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001859387	3055792361