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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	2934235		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779405	MR00398102	00	01/25/2021	01/25/2021	01/26/2021	67877019890	AMLODIPINE BESYLATE 5 MG TAB	5 MG	TABLET	90	90	85	94.44400	Replenished		1001801684
False	8948376		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793147	MR00195504	02	03/27/2023	03/27/2023	03/28/2023	67877019890	AMLODIPINE BESYLATE 5 MG TAB	5 MG	TABLET	90	90	5	5.55600	Replenished		1001801684
False	3026216		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000773343	MR00386717	03	03/02/2021	03/02/2021	03/03/2021	67877019890	AMLODIPINE BESYLATE 5 MG TAB	5 MG	TABLET	90	90	40	44.44400	Replenished		1001819785	3048855808
False	3003852		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000773630	MR00117914	03	02/25/2021	02/25/2021	02/26/2021	67877019890	AMLODIPINE BESYLATE 5 MG TAB	5 MG	TABLET	90	90	50	55.55600	Replenished		1001819785	3048855808
False	3031638		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000773343	MR00386717	03	03/02/2021	03/02/2021	03/03/2021	67877019890	AMLODIPINE BESYLATE 5 MG TAB	5 MG	TABLET	90	90	50	55.55600	Replenished		1001822785	3049139689
False	3048370		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780342	MR00177615	00	03/05/2021	03/05/2021	03/06/2021	67877019890	AMLODIPINE BESYLATE 5 MG TAB	5 MG	TABLET	90	90	40	44.44400	Replenished		1001822785	3049139689
False	3071222		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779145	MR00281435	02	03/10/2021	03/10/2021	03/11/2021	67877019890	AMLODIPINE BESYLATE 5 MG TAB	5 MG	TABLET	90	30	30	100.00000	Replenished		1001825961	3049810904
False	3052165		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780342	MR00177615	00	03/05/2021	03/05/2021	03/06/2021	67877019890	AMLODIPINE BESYLATE 5 MG TAB	5 MG	TABLET	90	90	50	55.55600	Replenished		1001825961	3049810904
False	3080837		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780508	MR00030549	00	03/12/2021	03/12/2021	03/13/2021	67877019890	AMLODIPINE BESYLATE 5 MG TAB	5 MG	TABLET	90	30	10	33.33300	Replenished		1001825961	3049810904
False	3110990		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779796	MR00145031	01	03/15/2021	03/15/2021	03/16/2021	67877019890	AMLODIPINE BESYLATE 5 MG TAB	5 MG	TABLET	90	30	30	100.00000	Replenished		1001829373	3050481049