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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	2934432		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776271	MR00278576	01	02/01/2021	02/01/2021	02/02/2021	16729018301	HYDROCHLOROTHIAZIDE 25 MG TAB	25 MG	TABLET	100	90	14	15.55600	Replenished		1001818667	988063364
False	2934431		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776271	MR00278576	01	02/01/2021	02/01/2021	02/02/2021	16729018301	HYDROCHLOROTHIAZIDE 25 MG TAB	25 MG	TABLET	100	90	76	84.44400	Replenished		1001805758
False	2934430		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777618	MR00151149	03	02/03/2021	02/03/2021	02/05/2021	16729018301	HYDROCHLOROTHIAZIDE 25 MG TAB	25 MG	TABLET	100	30	30	100.00000	Replenished		1001818667	988063364
False	2953777		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779950	MR00140632	00	02/16/2021	02/16/2021	02/17/2021	16729018301	HYDROCHLOROTHIAZIDE 25 MG TAB	25 MG	TABLET	100	15	15	100.00000	Replenished		1001818667	988063364
False	2976636		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780080	MR00024743	00	02/22/2021	02/22/2021	02/23/2021	16729018301	HYDROCHLOROTHIAZIDE 25 MG TAB	25 MG	TABLET	100	30	30	100.00000	Replenished		1001818667	988063364
False	3006967		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780195	2240145	00	02/26/2021	02/26/2021	02/28/2021	16729018301	HYDROCHLOROTHIAZIDE 25 MG TAB	25 MG	TABLET	100	90	11	12.22200	Replenished		1001818667	988063364
False	3012068		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780195	2240145	00	02/26/2021	02/26/2021	02/28/2021	16729018301	HYDROCHLOROTHIAZIDE 25 MG TAB	25 MG	TABLET	100	90	79	87.77800	Replenished		1001819373	988099025
False	3020627		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780230	2241340	00	03/01/2021	03/01/2021	03/02/2021	16729018301	HYDROCHLOROTHIAZIDE 25 MG TAB	25 MG	TABLET	100	90	21	23.33300	Replenished		1001819373	988099025
False	3024356		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780230	2241340	00	03/01/2021	03/01/2021	03/02/2021	16729018301	HYDROCHLOROTHIAZIDE 25 MG TAB	25 MG	TABLET	100	90	69	76.66700	Replenished		1001822140	3049139687
False	3026245		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778233	MR00043497	01	03/02/2021	03/02/2021	03/03/2021	16729018301	HYDROCHLOROTHIAZIDE 25 MG TAB	25 MG	TABLET	100	30	30	100.00000	Replenished		1001822140	3049139687