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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	9866556		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798970	MR00085254	00	07/05/2023	07/05/2023	07/06/2023	65862001901	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	21	21	100.00000	Replenished	08/28/2023	1002263052	3144881029
False	9941715		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799134	MR00296590	00	07/13/2023	07/13/2023	07/14/2023	65862001901	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	21	21	100.00000	Replenished	08/28/2023	1002263052	3144881029
False	10056543		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799492	MR00169717	00	08/01/2023	08/01/2023	08/02/2023	65862001901	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	21	21	100.00000	Replenished	08/28/2023	1002263052	3144881029
False	10100358		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799555	MR00117446	00	08/07/2023	08/07/2023	08/08/2023	65862001901	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	15	15	100.00000	Replenished	08/28/2023	1002263052	3144881029
False	10154873		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799716	MR00145031	00	08/14/2023	08/14/2023	08/15/2023	65862001901	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	21	21	100.00000	Replenished	08/28/2023	1002263052	3144881029
False	10241852		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799979	MR00250558	00	08/25/2023	08/25/2023	08/26/2023	65862001901	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	14	1	7.14300	Replenished	08/28/2023	1002263052	3144881029
False	2934379		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779232	MR00068492	00	01/15/2021	01/15/2021	01/16/2021	65862001901	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	40	14	35.00000	Replenished		1001797497
False	2934380		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779232	MR00068492	00	01/15/2021	01/15/2021	01/16/2021	65862001901	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	40	26	65.00000	Replenished		1001824882	3049647435
False	2934378		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779883	MR00127279	00	02/12/2021	02/12/2021	02/13/2021	65862001901	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	21	21	100.00000	Replenished		1001824882	3049647435
False	2948706		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779925	MR00229039	00	02/15/2021	02/15/2021	02/16/2021	65862001901	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	30	30	100.00000	Replenished		1001824882	3049647435