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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	4478907		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011730	MR00204569	00	09/09/2021	09/09/2021	09/10/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	90	90.00000	Replenished		1001921962	3067326643
False	4462886		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011716	MR00177844	00	09/07/2021	09/07/2021	09/08/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	30	10	33.33300	Replenished		1001921962	3067326643
False	4458902		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011716	MR00177844	00	09/07/2021	09/07/2021	09/08/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	30	20	66.66700	Replenished		1001919113	3067013097
False	4289849		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011683	MR00252736	00	08/16/2021	08/16/2021	08/17/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	60	100.00000	Replenished		1001919113	3067013097
False	4245934		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011668	MR00204569	00	08/10/2021	08/10/2021	08/11/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	20	20.00000	Replenished		1001919113	3067013097
False	4237828		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011668	MR00204569	00	08/10/2021	08/10/2021	08/11/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	80	80.00000	Replenished		1001902816	3064329314
False	4199188		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011651	MR00177844	00	08/04/2021	08/04/2021	08/05/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	30	10	33.33300	Replenished		1001899595	3063713217
False	4204857		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011651	MR00177844	00	08/04/2021	08/04/2021	08/05/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	30	20	66.66700	Replenished		1001902816	3064329314
False	4050024		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011599	MR00252736	00	07/14/2021	07/14/2021	07/15/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	60	100.00000	Replenished		1001899595	3063713217
False	4047206		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011597	MR00204569	00	07/13/2021	07/13/2021	07/14/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	30	30.00000	Replenished		1001899595	3063713217