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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	7094371		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790056	MR00204400	03	08/11/2022	08/11/2022	08/12/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1002130385	3112283351
False	4487846		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781550	MR00101113	02	09/10/2021	09/10/2021	09/11/2021	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1001956560	3073437016
False	6819580		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790056	MR00204400	02	07/07/2022	07/07/2022	07/08/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1002130385	3112283351
False	2933786		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778738	MR00038013	01	02/08/2021	02/08/2021	02/09/2021	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1001829373	3050481049
False	4184240		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781550	MR00101113	01	08/02/2021	08/02/2021	08/03/2021	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1001911378	3066004376
False	6505398		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790056	MR00204400	01	06/09/2022	06/09/2022	06/10/2022	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1002065805	3095834365
False	2976635		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780068	MR00204400	00	02/22/2021	02/22/2021	02/23/2021	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1001829373	3050481049
False	3033644		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780083	MR00038013	00	03/03/2021	03/03/2021	03/04/2021	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	30	100.00000	Replenished		1001829373	3050481049
False	3142202		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780649	MR00101113	00	03/19/2021	03/19/2021	03/20/2021	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	10	33.33300	Replenished		1001829373	3050481049
False	3144556		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780649	MR00101113	00	03/19/2021	03/19/2021	03/20/2021	51672402801	WARFARIN SODIUM 2 MG TABLET	2 MG	TABLET	100	30	20	66.66700	Replenished		1001871163	3057980095