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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	6749351		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012014	MR00204569	05	06/29/2022	06/29/2022	07/01/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	100	100.00000	Replenished		1002075533	3098184650
False	8606066		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	00	02/16/2023	02/16/2023	02/17/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	100	83.33300	Replenished		1002179601	3123877800
False	9133509		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	02	04/14/2023	04/14/2023	04/15/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	100	83.33300	Replenished	04/17/2023	1002208015	3130202879
False	9375341		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	03	05/15/2023	05/15/2023	05/16/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	100	83.33300	Replenished	05/18/2023	1002221191	3133750054
False	9752338		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	04	06/22/2023	06/22/2023	06/23/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	100	83.33300	Replenished	06/26/2023	1002236912	3137855545
False	10041571		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	05	07/28/2023	07/28/2023	07/29/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	96	80.00000	Replenished	08/16/2023	1002259761	3143593677
False	8847878		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	01	03/15/2023	03/15/2023	03/16/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	84	70.00000	Replenished		1002192761	3126917242
False	7245355		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012290	MR00204569	01	09/01/2022	09/01/2022	09/02/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	80	80.00000	Replenished		1002100079	3104971540
False	7474278		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012290	MR00204569	02	10/03/2022	10/03/2022	10/04/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	80	80.00000	Replenished		1002164575	3120074503
False	6802222		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012245	MR00252736	00	07/05/2022	07/05/2022	07/06/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	60	100.00000	Replenished		1002086833	3101665732