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			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	9996074		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799262	MR00092850	00	07/21/2023	07/21/2023	07/22/2023	61314063006	NEOMYC-POLYM-DEXAMETH EYE DROP	0.1 %	DROPS SUSP	5	5	5	100.00000	Replenished	08/22/2023	1002249643	3140846559