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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	10028398		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799419	MR00174136	00	07/27/2023	07/27/2023	07/28/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	90	18	20.00000	Replenished	08/22/2023	1002251495	3141657237
False	10033534		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799419	MR00174136	00	07/27/2023	07/27/2023	07/28/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	90	72	80.00000	Replenished	08/28/2023	1002263052	3144881029
False	10019929		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799391	MR00296590	00	07/26/2023	07/26/2023	07/27/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	90	8	8.88900	Replenished	08/22/2023	1002251223	3141466060
False	10025588		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799391	MR00296590	00	07/26/2023	07/26/2023	07/27/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	90	82	91.11100	Replenished	08/22/2023	1002251495	3141657237
False	9941701		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799135	MR00296590	00	07/13/2023	07/13/2023	07/14/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	5	5	100.00000	Replenished	08/22/2023	1002251223	3141466060
False	9738624		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798713	MR00158620	00	06/21/2023	06/21/2023	06/22/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	30	30	100.00000	Replenished	08/22/2023	1002251223	3141466060
False	9375333		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797889	MR00102464	00	05/11/2023	05/11/2023	05/16/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	30	30	100.00000	Replenished	05/22/2023	1002221811	3134071093
False	9295702		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797691	MR00209146	00	05/02/2023	05/02/2023	05/04/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	180	7	3.88800	Replenished	05/22/2023	1002221811	3134071093
False	9295700		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797691	MR00209146	00	05/02/2023	05/02/2023	05/04/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	180	10	5.55600	Replenished	05/08/2023	1002213418	3132524753
False	9276469		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797691	MR00209146	00	05/02/2023	05/02/2023	05/04/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	180	63	35.00000	Replenished	05/08/2023	1002213418	3132524753