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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	10110429		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795358	MR00229039	02	08/09/2023	08/09/2023	08/10/2023	55111046601	METOPROLOL SUCC ER 25 MG TAB	25 MG	TAB.SR 24H	100	90	80	88.88900	Replenished	08/11/2023	1002254446	3143082008
False	10085757		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796989	MR00389929	02	08/04/2023	08/04/2023	08/05/2023	55111046601	METOPROLOL SUCC ER 25 MG TAB	25 MG	TAB.SR 24H	100	30	20	66.66700	Replenished	08/11/2023	1002254446	3143082008
False	9933513		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794328	MR00027244	08	07/12/2023	07/12/2023	07/13/2023	55111046601	METOPROLOL SUCC ER 25 MG TAB	25 MG	TAB.SR 24H	100	30	30	100.00000	Replenished	08/22/2023	1002253366	3142468423
False	10065705		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795360	MR00165531	06	08/02/2023	08/02/2023	08/03/2023	55111046601	METOPROLOL SUCC ER 25 MG TAB	25 MG	TAB.SR 24H	100	30	30	100.00000	Replenished	08/22/2023	1002253366	3142468423
False	10080806		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796989	MR00389929	02	08/04/2023	08/04/2023	08/05/2023	55111046601	METOPROLOL SUCC ER 25 MG TAB	25 MG	TAB.SR 24H	100	30	10	33.33300	Replenished	08/22/2023	1002253366	3142468423
False	9894477		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797170	MR00041824	01	07/07/2023	07/07/2023	07/08/2023	55111046601	METOPROLOL SUCC ER 25 MG TAB	25 MG	TAB.SR 24H	100	90	30	33.33300	Replenished	08/22/2023	1002253366	3142468423
False	9873273		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795360	MR00165531	05	07/06/2023	07/06/2023	07/07/2023	55111046601	METOPROLOL SUCC ER 25 MG TAB	25 MG	TAB.SR 24H	100	30	30	100.00000	Replenished	07/07/2023	1002240234	3138951860
False	9888313		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797170	MR00041824	01	07/07/2023	07/07/2023	07/08/2023	55111046601	METOPROLOL SUCC ER 25 MG TAB	25 MG	TAB.SR 24H	100	90	60	66.66700	Replenished	07/08/2023	1002240234	3138951860
False	9822712		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797765	MR00389118	01	06/29/2023	06/29/2023	06/30/2023	55111046601	METOPROLOL SUCC ER 25 MG TAB	25 MG	TAB.SR 24H	100	60	10	16.66700	Replenished	07/06/2023	1002240234	3138951860
False	9724326		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794328	MR00027244	07	06/19/2023	06/19/2023	06/20/2023	55111046601	METOPROLOL SUCC ER 25 MG TAB	25 MG	TAB.SR 24H	100	30	30	100.00000	Replenished	07/03/2023	1002239218	3138618791