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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	3433654		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011424	BA76RRTH2GDY	00	04/27/2021	04/27/2021	04/28/2021	69315090401	LORAZEPAM 0.5 MG TABLET	0.5 MG	TABLET	100	20	20	100.00000	Replenished		1001849752	3054181638
False	9470457		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012706	MR00154246	00	05/24/2023	05/24/2023	05/25/2023	69315090401	LORAZEPAM 0.5 MG TABLET	0.5 MG	TABLET	100	3	3	100.00000	Replenished	06/09/2023	1002231800	3136126191
False	2934497		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011172	MR00206514	00	01/04/2021	01/04/2021	01/05/2021	69315090401	LORAZEPAM 0.5 MG TABLET	0.5 MG	TABLET	100	30	30	100.00000	Replenished		1001849752	3054181638
False	9626645		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012728	MR00206514	00	06/08/2023	06/08/2023	06/09/2023	69315090401	LORAZEPAM 0.5 MG TABLET	0.5 MG	TABLET	100	45	18	40.00000	Replenished	07/03/2023	1002239218	3138618790
False	9621081		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012728	MR00206514	00	06/08/2023	06/08/2023	06/09/2023	69315090401	LORAZEPAM 0.5 MG TABLET	0.5 MG	TABLET	100	45	27	60.00000	Replenished	06/12/2023	1002232051	3136303174
False	9996087		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012785	MR00206514	00	07/21/2023	07/21/2023	07/22/2023	69315090401	LORAZEPAM 0.5 MG TABLET	0.5 MG	TABLET	100	45	2	4.44400	Replenished	08/22/2023	1002249643	3140846558
False	10000390		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012785	MR00206514	00	07/21/2023	07/21/2023	07/22/2023	69315090401	LORAZEPAM 0.5 MG TABLET	0.5 MG	TABLET	100	45	43	95.55600	Replenished	08/22/2023	1002249847	3141005023
False	3350515		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011396	MR00283017	00	04/15/2021	04/15/2021	04/16/2021	69315090401	LORAZEPAM 0.5 MG TABLET	0.5 MG	TABLET	100	40	40	100.00000	Replenished		1001849752	3054181638
False	9544256		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012719	MR00283017	00	05/31/2023	05/31/2023	06/01/2023	69315090401	LORAZEPAM 0.5 MG TABLET	0.5 MG	TABLET	100	60	60	100.00000	Replenished	06/09/2023	1002231800	3136126191
False	9817054		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012719	MR00283017	01	06/28/2023	06/29/2023	06/30/2023	69315090401	LORAZEPAM 0.5 MG TABLET	0.5 MG	TABLET	100	60	22	36.66700	Replenished	07/03/2023	1002239218	3138618790