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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	5960101		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786731	MR00388213	03	03/28/2022	03/28/2022	03/29/2022	68382009716	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	90	30	30	100.00000	Replenished		1002039367	3090544681
False	6140509		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787357	MR00210929	01	04/20/2022	04/20/2022	04/21/2022	68382009716	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	90	90	30	33.33300	Replenished		1002075533	3098184651
False	6133332		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787357	MR00210929	01	04/20/2022	04/20/2022	04/21/2022	68382009716	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	90	90	60	66.66700	Replenished		1002039367	3090544681
False	6875262		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787357	MR00210929	02	07/13/2022	07/13/2022	07/14/2022	68382009716	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	90	90	90	100.00000	Replenished		1002079953	3099393355
False	6343464		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790317	MR00145513	00	05/18/2022	05/18/2022	05/19/2022	68382009716	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	90	30	30	100.00000	Replenished		1002075533	3098184651
False	6749344		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790317	MR00145513	01	06/29/2022	06/29/2022	07/01/2022	68382009716	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	90	30	30	100.00000	Replenished		1002075533	3098184651
False	7773189		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790317	MR00145513	04	11/09/2022	11/09/2022	11/10/2022	68382009716	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	90	30	30	100.00000	Replenished		1002130385	3112283351
False	8187349		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790317	MR00145513	05	12/30/2022	12/30/2022	01/01/2023	68382009716	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	90	30	30	100.00000	Replenished		1002164575	3120074504
False	8552479		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790317	MR00145513	06	02/08/2023	02/08/2023	02/11/2023	68382009716	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	90	30	30	100.00000	Replenished	04/21/2023	1002209232	3130801353
False	7625775		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793695	MR00210929	00	10/21/2022	10/21/2022	10/22/2022	68382009716	PAROXETINE HCL 10 MG TABLET	10 MG	TABLET	90	90	60	66.66700	Replenished		1002130385	3112283351