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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	2934279		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000775875	MR00156231	01	01/04/2021	01/04/2021	01/05/2021	13668001101	CITALOPRAM HBR 40 MG TABLET	40 MG	TABLET	100	30	10	33.33300	Replenished		1001816393	987952822
False	2934278		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000775875	MR00156231	01	01/04/2021	01/04/2021	01/05/2021	13668001101	CITALOPRAM HBR 40 MG TABLET	40 MG	TABLET	100	30	20	66.66700	Replenished		1001790379
False	2934276		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776330	MR00402958	02	01/28/2021	01/28/2021	01/29/2021	13668001101	CITALOPRAM HBR 40 MG TABLET	40 MG	TABLET	100	30	30	100.00000	Replenished		1001816393	987952822
False	2979692		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776330	MR00402958	03	02/23/2021	02/23/2021	02/24/2021	13668001101	CITALOPRAM HBR 40 MG TABLET	40 MG	TABLET	100	30	30	100.00000	Replenished		1001816393	987952822
False	2934277		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779407	MR00277658	00	01/25/2021	01/25/2021	01/26/2021	13668001101	CITALOPRAM HBR 40 MG TABLET	40 MG	TABLET	100	30	30	100.00000	Replenished		1001816393	987952822
False	3207035		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780874	MR00402958	00	03/30/2021	03/30/2021	03/31/2021	13668001101	CITALOPRAM HBR 40 MG TABLET	40 MG	TABLET	100	30	30	100.00000	Replenished		1001939012	3070433439
False	3485917		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780874	MR00402958	01	05/05/2021	05/05/2021	05/06/2021	13668001101	CITALOPRAM HBR 40 MG TABLET	40 MG	TABLET	100	30	30	100.00000	Replenished		1001939012	3070433439
False	4344385		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784238	MR00402958	00	08/23/2021	08/23/2021	08/24/2021	13668001101	CITALOPRAM HBR 40 MG TABLET	40 MG	TABLET	100	30	30	100.00000	Replenished		1001939012	3070433439
False	4710559		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784238	MR00402958	01	10/11/2021	10/11/2021	10/12/2021	13668001101	CITALOPRAM HBR 40 MG TABLET	40 MG	TABLET	100	30	10	33.33300	Replenished		1001939012	3070433439
False	4714224		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784238	MR00402958	01	10/11/2021	10/11/2021	10/12/2021	13668001101	CITALOPRAM HBR 40 MG TABLET	40 MG	TABLET	100	30	20	66.66700	Replenished		1001970980	3076395348