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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	2933791		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000778992	MR00021548	00	01/25/2021	01/25/2021	01/25/2021	68001019600	ESCITALOPRAM 10 MG TABLET	10 MG	TABLET	100	90	7	7.77800	Replenished		1001824882	3049647435
False	2933790		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000778992	MR00021548	00	01/25/2021	01/25/2021	01/25/2021	68001019600	ESCITALOPRAM 10 MG TABLET	10 MG	TABLET	100	90	83	92.22200	Replenished		1001801684
False	2933787		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000773020	MR00204569	10	02/12/2021	02/12/2021	02/13/2021	68001019600	ESCITALOPRAM 10 MG TABLET	10 MG	TABLET	100	30	30	100.00000	Replenished		1001824882	3049647435
False	3071242		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000773020	MR00204569	11	03/10/2021	03/10/2021	03/11/2021	68001019600	ESCITALOPRAM 10 MG TABLET	10 MG	TABLET	100	30	3	10.00000	Replenished		1001824882	3049647435
False	3075287		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000773020	MR00204569	11	03/10/2021	03/10/2021	03/11/2021	68001019600	ESCITALOPRAM 10 MG TABLET	10 MG	TABLET	100	30	27	90.00000	Replenished		1001826768	3050065356
False	2933788		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779121	MR00178696	01	02/10/2021	02/10/2021	02/11/2021	68001019600	ESCITALOPRAM 10 MG TABLET	10 MG	TABLET	100	30	30	100.00000	Replenished		1001824882	3049647435
False	2933789		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779764	MR00067064	00	02/09/2021	02/09/2021	02/10/2021	68001019600	ESCITALOPRAM 10 MG TABLET	10 MG	TABLET	100	30	30	100.00000	Replenished		1001824882	3049647435
False	3110983		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779764	MR00067064	01	03/15/2021	03/15/2021	03/16/2021	68001019600	ESCITALOPRAM 10 MG TABLET	10 MG	TABLET	100	30	30	100.00000	Replenished		1001826768	3050065356
False	3080826		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780451	4516	00	03/12/2021	03/12/2021	03/13/2021	68001019600	ESCITALOPRAM 10 MG TABLET	10 MG	TABLET	100	30	30	100.00000	Replenished		1001826768	3050065356
False	3110989		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780545	MR00178696	00	03/15/2021	03/15/2021	03/16/2021	68001019600	ESCITALOPRAM 10 MG TABLET	10 MG	TABLET	100	30	13	43.33300	Replenished		1001826768	3050065356