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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	8423285		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795724	MR00407402	00	01/26/2023	01/26/2023	01/27/2023	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	10	4	40.00000	Replenished	08/22/2023	1002251223	3141466060
False	8453394		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795773	MR00030324	00	01/30/2023	01/30/2023	02/01/2023	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	14	14	100.00000	Replenished	08/22/2023	1002251223	3141466060
False	8552490		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795920	MR00337955	00	02/06/2023	02/06/2023	02/11/2023	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	14	14	100.00000	Replenished	08/22/2023	1002251223	3141466060
False	8552439		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796004	MR00178696	00	02/09/2023	02/09/2023	02/11/2023	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	14	14	100.00000	Replenished	08/22/2023	1002251223	3141466060
False	8581288		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796111	MR00389170	00	02/14/2023	02/14/2023	02/15/2023	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	14	14	100.00000	Replenished	08/22/2023	1002251223	3141466060
False	8907254		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796847	MR00055148	00	03/22/2023	03/22/2023	03/23/2023	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	10	10	100.00000	Replenished	08/22/2023	1002251223	3141466060
False	9065574		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797178	MR00095217	00	04/07/2023	04/07/2023	04/08/2023	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	10	10	100.00000	Replenished	08/22/2023	1002251223	3141466060
False	9157485		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797372	MR00117446	00	04/18/2023	04/18/2023	04/19/2023	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	6	6	100.00000	Replenished	08/22/2023	1002251223	3141466060
False	9866557		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798969	MR00169717	00	07/05/2023	07/05/2023	07/06/2023	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	6	6	100.00000	Replenished	08/22/2023	1002251223	3141466060
False	10019911		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799363	MR00242068	00	07/26/2023	07/26/2023	07/27/2023	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	20	8	40.00000	Replenished	08/22/2023	1002251223	3141466060