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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	9129116		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012456	MR00192351	05	04/14/2023	04/14/2023	04/15/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	30	30	100.00000	Replenished	04/19/2023	1002208692	3130511069
False	8859114		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012456	MR00192351	04	03/17/2023	03/17/2023	03/18/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	30	30	100.00000	Replenished		1002193214	3127091766
False	9482443		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012529	MR00092991	04	05/25/2023	05/25/2023	05/26/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	135	43	31.85200	Replenished	05/30/2023	1002224253	3134809499
False	9490161		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012529	MR00092991	04	05/25/2023	05/25/2023	05/26/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	135	92	68.14800	Replenished	06/05/2023	1002226246	3135522745
False	8590189		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012456	MR00192351	03	02/15/2023	02/15/2023	02/16/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	30	30	100.00000	Replenished		1002181297	3124504730
False	9209522		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012529	MR00092991	03	04/24/2023	04/24/2023	04/25/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	135	22	16.29600	Replenished	05/02/2023	1002210717	3131427600
False	9217208		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012529	MR00092991	03	04/24/2023	04/24/2023	04/25/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	135	55	40.74100	Replenished	05/02/2023	1002210717	3131427600
False	9217209		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012529	MR00092991	03	04/24/2023	04/24/2023	04/25/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	135	58	42.96300	Replenished	05/04/2023	1002212085	3131746207
False	8890555		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012410	MR00170923	02	03/20/2023	03/20/2023	03/21/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	45	13	28.88900	Replenished		1002197595	3128646477
False	8885308		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012410	MR00170923	02	03/20/2023	03/20/2023	03/21/2023	00228202910	ALPRAZOLAM 0.5 MG TABLET	0.5 MG	TABLET	100	45	32	71.11100	Replenished		1002193992	3127402542