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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	5588615		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000785153	MR00195463	03	01/28/2022	02/07/2022	02/07/2022	00088221905	LANTUS SOLOSTAR 100 UNIT/ML	100/ML (3)	INSULN PEN	15	15	15	100.00000	Replenished		1002002666	3082799810
False	5700475		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000785153	MR00195463	04	02/22/2022	02/22/2022	02/22/2022	00088221905	LANTUS SOLOSTAR 100 UNIT/ML	100/ML (3)	INSULN PEN	15	15	15	100.00000	Replenished		1002010073	3084421079
False	5965873		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000785153	MR00195463	05	03/29/2022	03/29/2022	03/29/2022	00088221905	LANTUS SOLOSTAR 100 UNIT/ML	100/ML (3)	INSULN PEN	15	15	15	100.00000	Replenished		1002027177	3088118830
False	6194849		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000785153	MR00195463	06	04/28/2022	04/28/2022	04/28/2022	00088221905	LANTUS SOLOSTAR 100 UNIT/ML	100/ML (3)	INSULN PEN	15	15	15	100.00000	Replenished		1002043831	3091402520
False	6352239		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000785153	MR00195463	07	05/20/2022	05/20/2022	05/20/2022	00088221905	LANTUS SOLOSTAR 100 UNIT/ML	100/ML (3)	INSULN PEN	15	15	15	100.00000	Replenished		1002053733	3093649580
False	6553618		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000785153	MR00195463	08	06/17/2022	06/17/2022	06/17/2022	00088221905	LANTUS SOLOSTAR 100 UNIT/ML	100/ML (3)	INSULN PEN	15	15	15	100.00000	Replenished		1002067998	3096617326
False	6893075		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000785153	MR00195463	09	07/15/2022	07/15/2022	07/15/2022	00088221905	LANTUS SOLOSTAR 100 UNIT/ML	100/ML (3)	INSULN PEN	15	15	15	100.00000	Replenished		1002081161	3099576537
False	7112819		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000785153	MR00195463	10	08/15/2022	08/15/2022	08/15/2022	00088221905	LANTUS SOLOSTAR 100 UNIT/ML	100/ML (3)	INSULN PEN	15	15	15	100.00000	Replenished		1002094235	3102928342
False	7338529		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000785153	MR00195463	11	09/15/2022	09/15/2022	09/15/2022	00088221905	LANTUS SOLOSTAR 100 UNIT/ML	100/ML (3)	INSULN PEN	15	15	15	100.00000	Replenished		1002108257	3106376963
False	4939209		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000786188	MR00389371	00	11/11/2021	11/11/2021	11/11/2021	00088221905	LANTUS SOLOSTAR 100 UNIT/ML	100/ML (3)	INSULN PEN	15	15	15	100.00000	Replenished		1001958160	3073746994