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			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	6840625		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791403	MR00303827	00	07/08/2022	07/08/2022	07/09/2022	43598032675	CIPROFLOX-DEXAMETH OTIC SUSP	0.3 %-0.1%	DROPS SUSP	7.5	7.5	7.5	100.00000	Replenished		1002077877	3098828686