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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	3869881		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780578	MR00260341	03	06/25/2021	06/25/2021	06/26/2021	08290320122	BD UF NANO PEN NEEDLE 4MMX32G	32GX 5/32"	DIS NEEDLE	100	30	10	33.33300	Replenished		1001924089	3068049068
False	3863401		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780578	MR00260341	03	06/25/2021	06/25/2021	06/26/2021	08290320122	BD UF NANO PEN NEEDLE 4MMX32G	32GX 5/32"	DIS NEEDLE	100	30	20	66.66700	Replenished		1001880371	3059776593
False	2934366		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000777523	MR00260341	02	02/09/2021	02/09/2021	02/10/2021	08290320122	BD UF NANO PEN NEEDLE 4MMX32G	32GX 5/32"	DIS NEEDLE	100	30	30	100.00000	Replenished		1001827193	3050193214
False	3647960		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780578	MR00260341	02	05/27/2021	05/27/2021	05/28/2021	08290320122	BD UF NANO PEN NEEDLE 4MMX32G	32GX 5/32"	DIS NEEDLE	100	30	30	100.00000	Replenished		1001880371	3059776593
False	5997850		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000008001183	MR00260341	02	04/01/2022	04/01/2022	04/02/2022	08290320122	BD UF NANO PEN NEEDLE 4MMX32G	32GX 5/32"	DIS NEEDLE	100	100	10	10.00000	Replenished		1002110752	3107139680
False	5990968		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000008001183	MR00260341	02	04/01/2022	04/01/2022	04/02/2022	08290320122	BD UF NANO PEN NEEDLE 4MMX32G	32GX 5/32"	DIS NEEDLE	100	100	90	90.00000	Replenished		1002029938	3088434372
False	4832661		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779326	MR00097732	01	10/27/2021	10/27/2021	10/28/2021	08290320122	BD UF NANO PEN NEEDLE 4MMX32G	32GX 5/32"	DIS NEEDLE	100	100	10	10.00000	Replenished		1001976721	3077692822
False	4824144		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779326	MR00097732	01	10/27/2021	10/27/2021	10/28/2021	08290320122	BD UF NANO PEN NEEDLE 4MMX32G	32GX 5/32"	DIS NEEDLE	100	100	90	90.00000	Replenished		1001950376	3072152537
False	3390990		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780578	MR00260341	01	04/20/2021	04/20/2021	04/21/2021	08290320122	BD UF NANO PEN NEEDLE 4MMX32G	32GX 5/32"	DIS NEEDLE	100	30	30	100.00000	Replenished		1001880371	3059776593
False	5231566		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000008001183	MR00260341	01	12/20/2021	12/20/2021	12/21/2021	08290320122	BD UF NANO PEN NEEDLE 4MMX32G	32GX 5/32"	DIS NEEDLE	100	100	10	10.00000	Replenished		1002029938	3088434372