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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	10110423		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797577	MR00139617	01	08/09/2023	08/09/2023	08/10/2023	29300042001	AMITRIPTYLINE HCL 25 MG TAB	25 MG	TABLET	100	45	45	100.00000	Replenished	08/11/2023	1002254446	3143082008
False	10065695		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799497	MR00152015	00	08/02/2023	08/02/2023	08/03/2023	29300042001	AMITRIPTYLINE HCL 25 MG TAB	25 MG	TABLET	100	90	35	38.88900	Replenished	08/22/2023	1002252826	3142288891
False	10070713		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799497	MR00152015	00	08/02/2023	08/02/2023	08/03/2023	29300042001	AMITRIPTYLINE HCL 25 MG TAB	25 MG	TABLET	100	90	55	61.11100	Replenished	08/11/2023	1002254446	3143082008
False	9988313		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799246	MR00161301	00	07/20/2023	07/20/2023	07/21/2023	29300042001	AMITRIPTYLINE HCL 25 MG TAB	25 MG	TABLET	100	30	30	100.00000	Replenished	08/22/2023	1002252826	3142288891
False	9947103		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797059	MR00289747	01	07/13/2023	07/13/2023	07/14/2023	29300042001	AMITRIPTYLINE HCL 25 MG TAB	25 MG	TABLET	100	90	35	38.88900	Replenished	08/22/2023	1002252826	3142288891
False	9941704		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797059	MR00289747	01	07/13/2023	07/13/2023	07/14/2023	29300042001	AMITRIPTYLINE HCL 25 MG TAB	25 MG	TABLET	100	90	55	61.11100	Replenished	08/22/2023	1002247780	3140061853
False	9760653		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798765	MR00161301	00	06/23/2023	06/23/2023	06/24/2023	29300042001	AMITRIPTYLINE HCL 25 MG TAB	25 MG	TABLET	100	30	30	100.00000	Replenished	08/22/2023	1002247780	3140061853
False	9451166		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797578	MR00161301	01	05/22/2023	05/22/2023	05/23/2023	29300042001	AMITRIPTYLINE HCL 25 MG TAB	25 MG	TABLET	100	30	15	50.00000	Replenished	05/24/2023	1002222847	3134351839
False	9454188		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797578	MR00161301	01	05/22/2023	05/22/2023	05/23/2023	29300042001	AMITRIPTYLINE HCL 25 MG TAB	25 MG	TABLET	100	30	15	50.00000	Replenished	08/22/2023	1002247780	3140061853
False	9231660		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797577	MR00139617	00	04/26/2023	04/26/2023	04/27/2023	29300042001	AMITRIPTYLINE HCL 25 MG TAB	25 MG	TABLET	100	45	45	100.00000	Replenished	05/24/2023	1002222847	3134351839