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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	2963040		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000775269	MR00324885	02	02/18/2021	02/18/2021	02/19/2021	29300013001	HYDROCHLOROTHIAZIDE 12.5 MG CP	12.5 MG	CAPSULE	100	90	20	22.22200	Replenished		1001814475	987756775
False	2966250		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000775269	MR00324885	02	02/18/2021	02/18/2021	02/19/2021	29300013001	HYDROCHLOROTHIAZIDE 12.5 MG CP	12.5 MG	CAPSULE	100	90	70	77.77800	Replenished		1001814818	987756777
False	3589473		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000775269	MR00324885	03	05/18/2021	05/18/2021	05/19/2021	29300013001	HYDROCHLOROTHIAZIDE 12.5 MG CP	12.5 MG	CAPSULE	100	90	30	33.33300	Replenished		1001865893	3057164796
False	3582762		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000775269	MR00324885	03	05/18/2021	05/18/2021	05/19/2021	29300013001	HYDROCHLOROTHIAZIDE 12.5 MG CP	12.5 MG	CAPSULE	100	90	60	66.66700	Replenished		1001864958	3056990723
False	2958380		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777915	MR00279358	01	02/17/2021	02/17/2021	02/18/2021	29300013001	HYDROCHLOROTHIAZIDE 12.5 MG CP	12.5 MG	CAPSULE	100	90	10	11.11100	Replenished		1001812276	987651857
False	2961660		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777915	MR00279358	01	02/17/2021	02/17/2021	02/18/2021	29300013001	HYDROCHLOROTHIAZIDE 12.5 MG CP	12.5 MG	CAPSULE	100	90	80	88.88900	Replenished		1001814475	987756775
False	2988217		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779344	MR00319594	01	02/23/2021	02/24/2021	02/25/2021	29300013001	HYDROCHLOROTHIAZIDE 12.5 MG CP	12.5 MG	CAPSULE	100	30	10	33.33300	Replenished		1001816771	988000091
False	2994186		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779344	MR00319594	01	02/23/2021	02/24/2021	02/25/2021	29300013001	HYDROCHLOROTHIAZIDE 12.5 MG CP	12.5 MG	CAPSULE	100	30	20	66.66700	Replenished		1001841063	3052473905
False	3166425		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779344	MR00319594	02	03/24/2021	03/24/2021	03/25/2021	29300013001	HYDROCHLOROTHIAZIDE 12.5 MG CP	12.5 MG	CAPSULE	100	30	30	100.00000	Replenished		1001841063	3052473905
False	3426480		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779344	MR00319594	03	04/26/2021	04/26/2021	04/27/2021	29300013001	HYDROCHLOROTHIAZIDE 12.5 MG CP	12.5 MG	CAPSULE	100	30	30	100.00000	Replenished		1001864958	3056990723