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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	9774907		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	03	06/24/2023	06/24/2023	06/25/2023	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished	06/27/2023	1002237550	3138008261
False	9778911		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	03	06/24/2023	06/24/2023	06/25/2023	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished	06/27/2023	1002237550	3138008261
False	9778912		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	03	06/24/2023	06/24/2023	06/25/2023	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33400	Replenished	06/27/2023	1002237550	3138008261
False	9035402		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	02	04/04/2023	04/04/2023	04/05/2023	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished		1002199093	3129254774
False	9047129		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	02	04/04/2023	04/04/2023	04/05/2023	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished		1002199093	3129254774
False	9047130		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	02	04/04/2023	04/04/2023	04/05/2023	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33400	Replenished		1002199093	3129254774
False	8328091		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	01	01/16/2023	01/16/2023	01/17/2023	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished		1002164575	3120074504
False	8332415		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	01	01/16/2023	01/16/2023	01/17/2023	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished		1002164575	3120074504
False	8332416		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	01	01/16/2023	01/16/2023	01/17/2023	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33400	Replenished		1002164575	3120074504
False	7588063		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	00	10/17/2022	10/17/2022	10/18/2022	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished		1002123446	3109811595