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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	5443808		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787756	MR00161301	00	01/19/2022	01/19/2022	01/20/2022	55111018015	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1002013648	3085165921
False	5485437		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787879	MR00293789	00	01/25/2022	01/25/2022	01/26/2022	55111018015	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	30	30	100.00000	Replenished		1002013648	3085165921
False	6224679		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788166	MR00293789	00	05/02/2022	05/02/2022	05/03/2022	55111018015	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	30	30	100.00000	Replenished		1002067085	3096284899
False	5594230		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788173	MR00293789	00	02/07/2022	02/07/2022	02/08/2022	55111018015	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	60	60	100.00000	Replenished		1002013648	3085165921
False	5605434		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788194	MR00161301	00	02/08/2022	02/08/2022	02/09/2022	55111018015	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1002013648	3085165921
False	5748843		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788598	MR00161301	00	02/28/2022	02/28/2022	03/01/2022	55111018015	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1002013648	3085165921
False	5867363		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788913	MR00161301	00	03/15/2022	03/15/2022	03/16/2022	55111018015	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1002067085	3096284899
False	6016960		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789334	MR00161301	00	04/04/2022	04/04/2022	04/05/2022	55111018015	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1002067085	3096284899
False	6194875		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789852	MR00161301	00	04/27/2022	04/27/2022	04/28/2022	55111018015	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1002067085	3096284899
False	6533449		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789964	MR00293789	00	06/13/2022	06/13/2022	06/14/2022	55111018015	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	30	10	33.33300	Replenished		1002120077	3108911610