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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	3269382		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781055	MR00248486	00	04/07/2021	04/07/2021	04/08/2021	00527328946	LEVOTHYROXINE 175 MCG TABLET	175 MCG	TABLET	90	90	90	100.00000	Replenished		1001839075	3052306186
False	8574720		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796067	MR00018239	00	02/13/2023	02/13/2023	02/14/2023	00527328946	LEVOTHYROXINE 175 MCG TABLET	175 MCG	TABLET	90	30	30	100.00000	Replenished		1002199093	3129254774
False	8925062		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796067	MR00018239	01	03/23/2023	03/23/2023	03/24/2023	00527328946	LEVOTHYROXINE 175 MCG TABLET	175 MCG	TABLET	90	30	30	100.00000	Replenished		1002199093	3129254774
False	9035373		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797125	MR00289972	00	04/05/2023	04/05/2023	04/06/2023	00527328946	LEVOTHYROXINE 175 MCG TABLET	175 MCG	TABLET	90	30	30	100.00000	Replenished		1002199093	3129254774
False	9181910		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797491	MR00018239	00	04/21/2023	04/21/2023	04/22/2023	00527328946	LEVOTHYROXINE 175 MCG TABLET	175 MCG	TABLET	90	30	30	100.00000	Replenished	05/19/2023	1002221549	3133876132
False	9470456		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797491	MR00018239	01	05/24/2023	05/24/2023	05/25/2023	00527328946	LEVOTHYROXINE 175 MCG TABLET	175 MCG	TABLET	90	30	30	100.00000	Replenished	06/28/2023	1002238348	3138156842
False	9406095		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797804	MR00389011	00	05/08/2023	05/08/2023	05/17/2023	00527328946	LEVOTHYROXINE 175 MCG TABLET	175 MCG	TABLET	90	90	30	33.33300	Replenished	06/28/2023	1002238348	3138156842
False	9397849		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797804	MR00389011	00	05/08/2023	05/08/2023	05/17/2023	00527328946	LEVOTHYROXINE 175 MCG TABLET	175 MCG	TABLET	90	90	60	66.66700	Replenished	05/19/2023	1002221549	3133876132
False	9787477		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798789	MR00018239	00	06/26/2023	06/26/2023	06/27/2023	00527328946	LEVOTHYROXINE 175 MCG TABLET	175 MCG	TABLET	90	30	30	100.00000	Replenished	06/28/2023	1002238348	3138156842
False	10019901		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798789	MR00018239	01	07/26/2023	07/26/2023	07/27/2023	00527328946	LEVOTHYROXINE 175 MCG TABLET	175 MCG	TABLET	90	30	30	100.00000	Replenished	08/22/2023	1002253074	3142468422