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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	6802222		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012245	MR00252736	00	07/05/2022	07/05/2022	07/06/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	60	100.00000	Replenished		1002086833	3101665732
False	7023246		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012290	MR00204569	00	08/02/2022	08/02/2022	08/03/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	40	40.00000	Replenished		1002086833	3101665732
False	7029669		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012290	MR00204569	00	08/02/2022	08/02/2022	08/03/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	60	60.00000	Replenished		1002089116	3102298585
False	7075309		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012300	MR00252736	00	08/09/2022	08/09/2022	08/10/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	20	33.33300	Replenished		1002100079	3104971540
False	7068465		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012300	MR00252736	00	08/09/2022	08/09/2022	08/10/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	40	66.66700	Replenished		1002089116	3102298585
False	7317821		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012349	MR00252736	00	09/12/2022	09/12/2022	09/13/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	60	100.00000	Replenished		1002147857	3115655015
False	8328092		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012530	MR00252736	00	01/16/2023	01/16/2023	01/17/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	20	33.33300	Replenished		1002164575	3120074503
False	8332403		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012530	MR00252736	00	01/16/2023	01/16/2023	01/17/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	40	66.66700	Replenished		1002169597	3121860282
False	8460780		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012544	MR00204569	00	01/30/2023	01/30/2023	02/01/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	40	40.00000	Replenished		1002179601	3123877800
False	8453383		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012544	MR00204569	00	01/30/2023	01/30/2023	02/01/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	60	60.00000	Replenished		1002169597	3121860282