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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	8353500		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000790086	MR00162256	08	01/19/2023	01/19/2023	01/19/2023	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1002165418	3120576240
False	7997418		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000790086	MR00162256	07	12/07/2022	12/07/2022	12/07/2022	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1002143871	3115454488
False	7750803		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000790086	MR00162256	06	11/07/2022	11/07/2022	11/07/2022	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1002129814	3111983748
False	7486256		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000790086	MR00162256	05	10/05/2022	10/05/2022	10/05/2022	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1002118784	3108448503
False	8765209		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000793356	MR00209146	05	03/06/2023	03/06/2023	03/06/2023	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1002185583	3125815325
False	6545421		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786989	MR00037445	05	05/18/2022	05/18/2022	06/17/2022	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1002067678	3096617324
False	4927281		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000783210	MR00108206	04	11/10/2021	11/10/2021	11/10/2021	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1001957713	3073585555
False	6066732		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000786989	MR00037445	04	04/11/2022	04/11/2022	04/11/2022	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1002033642	3089441266
False	7265982		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000790086	MR00162256	04	09/06/2022	09/06/2022	09/06/2022	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1002100974	3105275859
False	8508469		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000793356	MR00209146	04	02/06/2023	02/06/2023	02/06/2023	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1002171376	3122543058