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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	9148375		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797360	MR00369135	00	04/17/2023	04/17/2023	04/18/2023	00173060202	FLOVENT 100 MCG DISKUS	100 MCG	DISK W/DEV	60	60	60	100.00000	Replenished	04/19/2023	1002208692	3130511160