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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	2934424		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011251	MR00324885	00	02/08/2021	02/08/2021	02/09/2021	68180078001	ZOLPIDEM TART ER 12.5 MG TAB	12.5 MG	TAB MPHASE	100	30	30	100.00000	Replenished		1001858827	3055792099
False	3071210		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011317	MR00324885	00	03/10/2021	03/10/2021	03/11/2021	68180078001	ZOLPIDEM TART ER 12.5 MG TAB	12.5 MG	TAB MPHASE	100	30	30	100.00000	Replenished		1001858827	3055792099
False	3361553		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011398	MR00324885	00	04/16/2021	04/16/2021	04/17/2021	68180078001	ZOLPIDEM TART ER 12.5 MG TAB	12.5 MG	TAB MPHASE	100	30	30	100.00000	Replenished		1001858827	3055792099
False	3549265		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011464	MR00324885	00	05/13/2021	05/13/2021	05/14/2021	68180078001	ZOLPIDEM TART ER 12.5 MG TAB	12.5 MG	TAB MPHASE	100	30	10	33.33300	Replenished		1001858827	3055792099
False	3555594		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011464	MR00324885	00	05/13/2021	05/13/2021	05/14/2021	68180078001	ZOLPIDEM TART ER 12.5 MG TAB	12.5 MG	TAB MPHASE	100	30	20	66.66700	Replenished		1001902393	3064140710
False	3775708		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011531	MR00324885	00	06/16/2021	06/16/2021	06/17/2021	68180078001	ZOLPIDEM TART ER 12.5 MG TAB	12.5 MG	TAB MPHASE	100	30	30	100.00000	Replenished		1001902393	3064140710
False	4050032		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011531	MR00324885	01	07/14/2021	07/14/2021	07/15/2021	68180078001	ZOLPIDEM TART ER 12.5 MG TAB	12.5 MG	TAB MPHASE	100	30	30	100.00000	Replenished		1001902393	3064140710
False	4231921		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011665	MR00391218	00	08/09/2021	08/09/2021	08/10/2021	68180078001	ZOLPIDEM TART ER 12.5 MG TAB	12.5 MG	TAB MPHASE	100	30	10	33.33300	Replenished		1002070629	3097050647
False	4228252		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011665	MR00391218	00	08/09/2021	08/09/2021	08/10/2021	68180078001	ZOLPIDEM TART ER 12.5 MG TAB	12.5 MG	TAB MPHASE	100	30	20	66.66700	Replenished		1001902393	3064140710
False	4790161		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011665	MR00391218	01	10/22/2021	10/22/2021	10/23/2021	68180078001	ZOLPIDEM TART ER 12.5 MG TAB	12.5 MG	TAB MPHASE	100	30	30	100.00000	Replenished		1002070629	3097050647