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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	8453396		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794105	MR00324885	03	01/30/2023	01/30/2023	02/01/2023	29300042101	AMITRIPTYLINE HCL 50 MG TAB	50 MG	TABLET	100	30	10	33.33300	Replenished		1002169597	3121860283
False	9930420		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798565	MR00109185	01	07/11/2023	07/11/2023	07/12/2023	29300042101	AMITRIPTYLINE HCL 50 MG TAB	50 MG	TABLET	100	60	10	16.66700	Replenished	08/22/2023	1002248829	3140665212
False	8460776		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794105	MR00324885	03	01/30/2023	01/30/2023	02/01/2023	29300042101	AMITRIPTYLINE HCL 50 MG TAB	50 MG	TABLET	100	30	20	66.66700	Replenished	04/21/2023	1002209232	3130801353
False	9166368		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797442	MR00109185	00	04/19/2023	04/19/2023	04/20/2023	29300042101	AMITRIPTYLINE HCL 50 MG TAB	50 MG	TABLET	100	60	20	33.33300	Replenished	04/21/2023	1002209232	3130801353
False	9678724		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798565	MR00109185	00	06/14/2023	06/14/2023	06/15/2023	29300042101	AMITRIPTYLINE HCL 50 MG TAB	50 MG	TABLET	100	60	20	33.33300	Replenished	08/22/2023	1002247471	3140061852
False	8703683		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794105	MR00324885	04	02/27/2023	02/27/2023	03/01/2023	29300042101	AMITRIPTYLINE HCL 50 MG TAB	50 MG	TABLET	100	30	30	100.00000	Replenished	04/21/2023	1002209232	3130801353
False	8936608		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794105	MR00324885	05	03/25/2023	03/25/2023	03/26/2023	29300042101	AMITRIPTYLINE HCL 50 MG TAB	50 MG	TABLET	100	30	30	100.00000	Replenished	04/21/2023	1002209232	3130801353
False	9276483		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794105	MR00324885	06	05/03/2023	05/03/2023	05/04/2023	29300042101	AMITRIPTYLINE HCL 50 MG TAB	50 MG	TABLET	100	30	30	100.00000	Replenished	05/19/2023	1002221549	3133876132
False	9397872		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797442	MR00109185	01	05/17/2023	05/17/2023	05/18/2023	29300042101	AMITRIPTYLINE HCL 50 MG TAB	50 MG	TABLET	100	60	30	50.00000	Replenished	05/19/2023	1002221549	3133876132
False	9406099		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797442	MR00109185	01	05/17/2023	05/17/2023	05/18/2023	29300042101	AMITRIPTYLINE HCL 50 MG TAB	50 MG	TABLET	100	60	30	50.00000	Replenished	06/16/2023	1002234551	3136913250