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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	9152105		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797363	MR00018670	00	04/17/2023	04/17/2023	04/18/2023	00093314701	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	28	6	21.42900	Replenished	05/19/2023	1002221549	3133876132
False	9276496		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797675	MR00256491	00	05/02/2023	05/02/2023	05/04/2023	00093314701	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	20	20	100.00000	Replenished	05/19/2023	1002221549	3133876132
False	9276439		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797710	MR00126335	00	05/02/2023	05/02/2023	05/04/2023	00093314701	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	30	30	100.00000	Replenished	05/19/2023	1002221549	3133876132
False	9375397		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797947	MR00171522	00	05/15/2023	05/15/2023	05/16/2023	00093314701	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	21	21	100.00000	Replenished	05/19/2023	1002221549	3133876132
False	9375335		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797954	MR00204569	00	05/15/2023	05/15/2023	05/16/2023	00093314701	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	15	15	100.00000	Replenished	05/19/2023	1002221549	3133876132
False	9397864		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798002	MR00037851	00	05/17/2023	05/17/2023	05/18/2023	00093314701	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	15	8	53.33300	Replenished	05/19/2023	1002221549	3133876132
False	8913109		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796850	MR00386717	00	03/22/2023	03/22/2023	03/23/2023	00093314701	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	21	9	42.85700	Replenished	04/19/2023	1002208692	3130511160
False	8925070		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796922	MR00180356	00	03/24/2023	03/24/2023	03/25/2023	00093314701	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	20	20	100.00000	Replenished	04/19/2023	1002208692	3130511160
False	9035380		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797110	MR00174697	00	04/04/2023	04/04/2023	04/05/2023	00093314701	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	21	21	100.00000	Replenished	04/19/2023	1002208692	3130511160
False	9065573		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797180	MR00127901	00	04/07/2023	04/07/2023	04/08/2023	00093314701	CEPHALEXIN 500 MG CAPSULE	500 MG	CAPSULE	100	28	28	100.00000	Replenished	04/19/2023	1002208692	3130511160