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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	4859349		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785900	MR00198270	00	11/01/2021	11/01/2021	11/02/2021	64679092602	ENALAPRIL MALEATE 20 MG TAB	20 MG	TABLET	100	30	30	100.00000	Replenished		1002008728	3084278400
False	5015895		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785900	MR00198270	01	11/22/2021	11/22/2021	11/23/2021	64679092602	ENALAPRIL MALEATE 20 MG TAB	20 MG	TABLET	100	30	30	100.00000	Replenished		1002008728	3084278400
False	5452710		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787809	MR00198270	00	01/20/2022	01/20/2022	01/21/2022	64679092602	ENALAPRIL MALEATE 20 MG TAB	20 MG	TABLET	100	30	30	100.00000	Replenished		1002008728	3084278400
False	5689602		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787809	MR00198270	01	02/21/2022	02/21/2022	02/22/2022	64679092602	ENALAPRIL MALEATE 20 MG TAB	20 MG	TABLET	100	30	10	33.33300	Replenished		1002008728	3084278400
False	5692434		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787809	MR00198270	01	02/21/2022	02/21/2022	02/22/2022	64679092602	ENALAPRIL MALEATE 20 MG TAB	20 MG	TABLET	100	30	20	66.66700	Replenished		1002057770	3094089034
False	5926970		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789077	MR00198270	00	03/22/2022	03/22/2022	03/23/2022	64679092602	ENALAPRIL MALEATE 20 MG TAB	20 MG	TABLET	100	30	30	100.00000	Replenished		1002057770	3094089034
False	6148742		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789077	MR00198270	01	04/21/2022	04/21/2022	04/22/2022	64679092602	ENALAPRIL MALEATE 20 MG TAB	20 MG	TABLET	100	30	30	100.00000	Replenished		1002057770	3094089034
False	6377264		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789077	MR00198270	02	05/23/2022	05/23/2022	05/24/2022	64679092602	ENALAPRIL MALEATE 20 MG TAB	20 MG	TABLET	100	30	20	66.66700	Replenished		1002057770	3094089034
False	6383776		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789077	MR00198270	02	05/23/2022	05/23/2022	05/24/2022	64679092602	ENALAPRIL MALEATE 20 MG TAB	20 MG	TABLET	100	30	10	33.33300	Replenished		1002096808	3104187393
False	6658525		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789077	MR00198270	03	06/22/2022	06/22/2022	06/23/2022	64679092602	ENALAPRIL MALEATE 20 MG TAB	20 MG	TABLET	100	30	30	100.00000	Replenished		1002096808	3104187393