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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	6094253		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781948	MR00389011	03	04/14/2022	04/14/2022	04/15/2022	43547042409	LOSARTAN-HCTZ 100-25 MG TAB	100MG-25MG	TABLET	90	90	90	100.00000	Replenished		1002036295	3089903740
False	6121966		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787547	MR00101311	01	04/18/2022	04/18/2022	04/19/2022	43547042409	LOSARTAN-HCTZ 100-25 MG TAB	100MG-25MG	TABLET	90	90	90	100.00000	Replenished		1002037486	3090307729
False	6176432		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789766	MR00112843	00	04/25/2022	04/25/2022	04/26/2022	43547042409	LOSARTAN-HCTZ 100-25 MG TAB	100MG-25MG	TABLET	90	90	90	100.00000	Replenished		1002043049	3091080286
False	7013541		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789766	MR00112843	01	08/01/2022	08/01/2022	08/02/2022	43547042409	LOSARTAN-HCTZ 100-25 MG TAB	100MG-25MG	TABLET	90	90	90	100.00000	Replenished		1002086492	3101518230
False	7562616		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790880	MR00101311	01	10/14/2022	10/14/2022	10/15/2022	43547042409	LOSARTAN-HCTZ 100-25 MG TAB	100MG-25MG	TABLET	90	90	90	100.00000	Replenished		1002122389	3109361369
False	6884060		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791541	MR00389011	00	07/14/2022	07/14/2022	07/15/2022	43547042409	LOSARTAN-HCTZ 100-25 MG TAB	100MG-25MG	TABLET	90	90	90	100.00000	Replenished		1002080842	3099576536
False	7588075		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791541	MR00389011	01	10/17/2022	10/17/2022	10/18/2022	43547042409	LOSARTAN-HCTZ 100-25 MG TAB	100MG-25MG	TABLET	90	90	90	100.00000	Replenished		1002123446	3109811595
False	6558708		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790880	MR00101311	00	06/16/2022	06/16/2022	06/17/2022	43547042409	LOSARTAN-HCTZ 100-25 MG TAB	100MG-25MG	TABLET	90	90	60	66.66700	Replenished		1002075533	3098184651
False	7667195		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793804	MR00112843	00	10/27/2022	10/27/2022	10/28/2022	43547042409	LOSARTAN-HCTZ 100-25 MG TAB	100MG-25MG	TABLET	90	90	60	66.66700	Replenished		1002126984	3110896803
False	6224728		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785301	MR00340166	05	05/03/2022	05/03/2022	05/04/2022	43547042409	LOSARTAN-HCTZ 100-25 MG TAB	100MG-25MG	TABLET	90	30	30	100.00000	Replenished		1002067998	3096617326