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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	5858570		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788865	MR00095217	00	03/11/2022	03/14/2022	03/16/2022	50742017501	ISOSORBIDE MONONIT ER 30 MG TB	30 MG	TAB.SR 24H	100	15	15	100.00000	Replenished		1002067998	3096617326
False	5984549		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788865	MR00095217	01	03/31/2022	03/31/2022	04/01/2022	50742017501	ISOSORBIDE MONONIT ER 30 MG TB	30 MG	TAB.SR 24H	100	15	15	100.00000	Replenished		1002067998	3096617326
False	6133316		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788865	MR00095217	02	04/20/2022	04/20/2022	04/21/2022	50742017501	ISOSORBIDE MONONIT ER 30 MG TB	30 MG	TAB.SR 24H	100	15	15	100.00000	Replenished		1002067998	3096617326
False	6235965		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788865	MR00095217	03	05/04/2022	05/04/2022	05/05/2022	50742017501	ISOSORBIDE MONONIT ER 30 MG TB	30 MG	TAB.SR 24H	100	15	15	100.00000	Replenished		1002067998	3096617326
False	6324093		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788865	MR00095217	04	05/16/2022	05/16/2022	05/17/2022	50742017501	ISOSORBIDE MONONIT ER 30 MG TB	30 MG	TAB.SR 24H	100	15	15	100.00000	Replenished		1002067998	3096617326
False	6449123		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788865	MR00095217	05	06/02/2022	06/02/2022	06/03/2022	50742017501	ISOSORBIDE MONONIT ER 30 MG TB	30 MG	TAB.SR 24H	100	15	15	100.00000	Replenished		1002067998	3096617326
False	6558709		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788865	MR00095217	06	06/16/2022	06/16/2022	06/17/2022	50742017501	ISOSORBIDE MONONIT ER 30 MG TB	30 MG	TAB.SR 24H	100	15	5	33.33300	Replenished		1002119084	3108617904
False	6553625		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788865	MR00095217	06	06/16/2022	06/16/2022	06/17/2022	50742017501	ISOSORBIDE MONONIT ER 30 MG TB	30 MG	TAB.SR 24H	100	15	10	66.66700	Replenished		1002067998	3096617326
False	6749329		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788865	MR00095217	07	06/30/2022	06/30/2022	07/01/2022	50742017501	ISOSORBIDE MONONIT ER 30 MG TB	30 MG	TAB.SR 24H	100	15	15	100.00000	Replenished		1002119084	3108617904
False	6884057		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791526	MR00095217	00	07/14/2022	07/14/2022	07/15/2022	50742017501	ISOSORBIDE MONONIT ER 30 MG TB	30 MG	TAB.SR 24H	100	15	15	100.00000	Replenished		1002119084	3108617904