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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	10206027		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793997	MR00395196	09	08/21/2023	08/21/2023	08/22/2023	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	23	76.66700	Replenished	08/23/2023	1002261840	3144399971
False	10019916		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799386	MR00018670	00	07/26/2023	07/26/2023	07/27/2023	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	30	100.00000	Replenished	08/23/2023	1002261840	3144399971
False	9988309		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793997	MR00395196	08	07/20/2023	07/20/2023	07/21/2023	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	30	100.00000	Replenished	08/23/2023	1002261840	3144399971
False	9848994		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796526	MR00248646	03	07/03/2023	07/03/2023	07/04/2023	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	13	43.33300	Replenished	07/06/2023	1002240234	3138951860
False	9851479		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796526	MR00248646	03	07/03/2023	07/03/2023	07/04/2023	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	17	56.66700	Replenished	08/23/2023	1002261840	3144399971
False	9793576		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798830	MR00018670	00	06/27/2023	06/27/2023	06/28/2023	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	30	100.00000	Replenished	07/06/2023	1002240234	3138951860
False	9728649		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793997	MR00395196	07	06/20/2023	06/20/2023	06/21/2023	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	30	100.00000	Replenished	07/06/2023	1002240234	3138951860
False	9544254		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796526	MR00248646	02	05/30/2023	05/30/2023	06/01/2023	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	3	10.00000	Replenished	06/05/2023	1002226246	3135522746
False	9558078		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796526	MR00248646	02	05/30/2023	05/30/2023	06/01/2023	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	27	90.00000	Replenished	07/06/2023	1002240234	3138951860
False	9482452		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798183	MR00018670	00	05/25/2023	05/25/2023	05/26/2023	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	30	100.00000	Replenished	06/05/2023	1002226246	3135522746