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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	3350517		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774985	MR00210929	03	04/15/2021	04/15/2021	04/16/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	90	30	33.33300	Replenished		1001843888	3053146133
False	3357321		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774985	MR00210929	03	04/15/2021	04/15/2021	04/16/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	90	30	33.33300	Replenished		1001843888	3053146133
False	3357322		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774985	MR00210929	03	04/15/2021	04/15/2021	04/16/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	90	30	33.33400	Replenished		1001843888	3053146133
False	3655422		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777578	MR00145513	03	05/28/2021	05/28/2021	05/29/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	30	30	100.00000	Replenished		1001866451	3057164798
False	3414266		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777578	MR00145513	02	04/23/2021	04/23/2021	04/24/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	30	30	100.00000	Replenished		1001848263	3053810034
False	5664475		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786731	MR00388213	02	02/16/2022	02/16/2022	02/17/2022	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	30	30	100.00000	Replenished		1002007603	3084006129
False	3166413		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777578	MR00145513	01	03/24/2021	03/24/2021	03/25/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	30	30	100.00000	Replenished		1001831820	3050993427
False	4040662		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779859	MR00389502	01	07/13/2021	07/13/2021	07/14/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	30	30	100.00000	Replenished		1001889580	3061517655
False	4738381		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784616	MR00145513	01	10/13/2021	10/13/2021	10/14/2021	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	30	30	100.00000	Replenished		1001940281	3070884325
False	5461237		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786731	MR00388213	01	01/21/2022	01/21/2022	01/22/2022	68382009706	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	30	30	30	100.00000	Replenished		1001993278	3080996427