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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	9933529		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799101	MR00413229	00	07/12/2023	07/12/2023	07/13/2023	00713067831	NYSTATIN 100,000 UNIT/GM CREAM	100000/G	CREAM(GM)	30	30	30	100.00000	Replenished	08/22/2023	1002247471	3140061852
False	10180325		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796115	MR00178696	01	08/17/2023	08/17/2023	08/18/2023	00713067831	NYSTATIN 100,000 UNIT/GM CREAM	100000/G	CREAM(GM)	30	30	30	100.00000	Replenished	08/21/2023	1002260563	3144082982
False	9470466		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798175	MR00178696	00	05/24/2023	05/24/2023	05/25/2023	00713067831	NYSTATIN 100,000 UNIT/GM CREAM	100000/G	CREAM(GM)	30	30	30	100.00000	Replenished	05/26/2023	1002223394	3134652724
False	9375379		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797946	MR00171522	00	05/15/2023	05/15/2023	05/16/2023	00713067831	NYSTATIN 100,000 UNIT/GM CREAM	100000/G	CREAM(GM)	30	30	30	100.00000	Replenished	05/18/2023	1002221191	3133750055
False	3502074		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781754	MR00059308	00	05/07/2021	05/07/2021	05/08/2021	00713067831	NYSTATIN 100,000 UNIT/GM CREAM	100000/G	CREAM(GM)	30	30	30	100.00000	Replenished		1001855254	3055135221
False	4034047		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783283	MR00289747	00	07/12/2021	07/12/2021	07/13/2021	00713067831	NYSTATIN 100,000 UNIT/GM CREAM	100000/G	CREAM(GM)	30	30	30	100.00000	Replenished		1001889250	3061354275
False	4128160		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783577	MR00152162	00	07/26/2021	07/26/2021	07/27/2021	00713067831	NYSTATIN 100,000 UNIT/GM CREAM	100000/G	CREAM(GM)	30	30	30	100.00000	Replenished		1001898902	3063301736
False	4404224		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784381	MR00108206	00	08/30/2021	08/30/2021	08/31/2021	00713067831	NYSTATIN 100,000 UNIT/GM CREAM	100000/G	CREAM(GM)	30	30	30	100.00000	Replenished		1001916855	3066262939
False	4727278		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785488	MR00038013	00	10/13/2021	10/13/2021	10/14/2021	00713067831	NYSTATIN 100,000 UNIT/GM CREAM	100000/G	CREAM(GM)	30	30	30	100.00000	Replenished		1001939962	3070708844
False	5059621		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785488	MR00038013	01	11/29/2021	11/29/2021	11/30/2021	00713067831	NYSTATIN 100,000 UNIT/GM CREAM	100000/G	CREAM(GM)	30	30	30	100.00000	Replenished		1001965091	3075301281