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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	10218094		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799876	MR00373597	00	08/22/2023	08/22/2023	08/23/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	78	86.66700	Replenished	08/24/2023	1002262221	3144548022
False	10180313		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795476	MR00252190	04	08/17/2023	08/17/2023	08/18/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	30	8	26.66700	Replenished	08/21/2023	1002260563	3144082982
False	10185477		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795476	MR00252190	04	08/17/2023	08/17/2023	08/18/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	30	22	73.33300	Replenished	08/24/2023	1002262221	3144548022
False	10171631		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792869	MR00117446	11	08/16/2023	08/16/2023	08/17/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	30	30	100.00000	Replenished	08/21/2023	1002260563	3144082982
False	10118237		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799657	MR00331064	00	08/10/2023	08/10/2023	08/11/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	28	31.11100	Replenished	08/14/2023	1002254688	3143269122
False	10123682		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799657	MR00331064	00	08/10/2023	08/10/2023	08/11/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	62	68.88900	Replenished	08/21/2023	1002260563	3144082982
False	10100364		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795951	MR00223918	02	08/08/2023	08/08/2023	08/09/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	90	90	100.00000	Replenished	08/10/2023	1002254151	3142973963
False	10107404		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792231	MR00205174	11	08/07/2023	08/07/2023	08/08/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	30	2	6.66700	Replenished	08/10/2023	1002254151	3142973963
False	10100361		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792231	MR00205174	11	08/07/2023	08/07/2023	08/08/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	30	28	93.33300	Replenished	08/10/2023	1002254151	3142973963
False	10100387		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799563	MR00234113	00	08/07/2023	08/07/2023	08/08/2023	68462039601	OMEPRAZOLE DR 20 MG CAPSULE	20 MG	CAPSULE DR	100	180	10	5.55600	Replenished	08/10/2023	1002254151	3142973963