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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	8901517		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792773	MR00210929	02	03/21/2023	03/21/2023	03/22/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	40	44.44400	Replenished		1002199438	3129427833
False	8893521		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792773	MR00210929	02	03/21/2023	03/21/2023	03/22/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	50	55.55600	Replenished		1002194250	3127552216
False	8750815		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	04	03/04/2023	03/04/2023	03/05/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	10	16.66700	Replenished		1002185066	3125534406
False	8757231		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	04	03/04/2023	03/04/2023	03/05/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	50	83.33300	Replenished		1002194250	3127552216
False	9051465		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	05	04/06/2023	04/06/2023	04/07/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	60	100.00000	Replenished		1002199438	3129427833
False	9406098		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	06	05/08/2023	05/08/2023	05/17/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	20	33.33300	Replenished	05/22/2023	1002222095	3134071095
False	9397888		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	06	05/08/2023	05/08/2023	05/17/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	40	66.66700	Replenished	05/19/2023	1002221549	3133876132
False	9610754		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	07	06/07/2023	06/07/2023	06/08/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	60	100.00000	Replenished	06/09/2023	1002231800	3136126192
False	9873274		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	08	07/06/2023	07/06/2023	07/07/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	60	100.00000	Replenished	08/22/2023	1002253074	3142468422
False	10100356		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793838	MR00230427	09	08/08/2023	08/08/2023	08/09/2023	29300041901	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	60	100.00000	Replenished	08/14/2023	1002254688	3143269122