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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	7773181		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794099	MR00204400	00	11/09/2022	11/09/2022	11/10/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	10	33.33300	Replenished		1002130385	3112283351
False	7442551		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793150	MR00204400	00	09/28/2022	09/28/2022	09/29/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1002130385	3112283351
False	7094371		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790056	MR00204400	03	08/11/2022	08/11/2022	08/12/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1002130385	3112283351
False	6819580		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790056	MR00204400	02	07/07/2022	07/07/2022	07/08/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1002130385	3112283351
False	6505398		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790056	MR00204400	01	06/09/2022	06/09/2022	06/10/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1002065805	3095834365
False	6251393		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790056	MR00204400	00	05/05/2022	05/05/2022	05/06/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1002065805	3095834365
False	6036050		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789419	MR00204400	00	04/07/2022	04/07/2022	04/08/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1002065805	3095834365
False	5793256		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788681	MR00204400	00	03/03/2022	03/03/2022	03/04/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	10	33.33300	Replenished		1002065805	3095834365
False	5786280		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788681	MR00204400	00	03/03/2022	03/03/2022	03/04/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	20	66.66700	Replenished		1002015325	3085493191
False	5485445		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787882	MR00204400	00	01/25/2022	01/25/2022	01/26/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1002015325	3085493191