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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	10162444		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799144	MR00256491	01	08/15/2023	08/15/2023	08/16/2023	62332014231	CELECOXIB 200 MG CAPSULE	200 MG	CAPSULE	100	60	26	43.33300	Replenished	08/17/2023	1002259987	3143744568
False	10110426		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798597	MR00386503	02	08/09/2023	08/09/2023	08/10/2023	62332014231	CELECOXIB 200 MG CAPSULE	200 MG	CAPSULE	100	60	60	100.00000	Replenished	08/17/2023	1002259987	3143744568
False	10036259		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796724	MR00027244	05	07/28/2023	07/28/2023	07/29/2023	62332014231	CELECOXIB 200 MG CAPSULE	200 MG	CAPSULE	100	30	30	100.00000	Replenished	08/22/2023	1002251766	3141657239
False	10041576		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799448	MR00229039	00	07/28/2023	07/28/2023	07/29/2023	62332014231	CELECOXIB 200 MG CAPSULE	200 MG	CAPSULE	100	180	14	7.77700	Replenished	08/17/2023	1002259987	3143744568
False	10036270		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799448	MR00229039	00	07/28/2023	07/28/2023	07/29/2023	62332014231	CELECOXIB 200 MG CAPSULE	200 MG	CAPSULE	100	180	66	36.66700	Replenished	08/22/2023	1002251766	3141657239
False	10041575		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799448	MR00229039	00	07/28/2023	07/28/2023	07/29/2023	62332014231	CELECOXIB 200 MG CAPSULE	200 MG	CAPSULE	100	180	100	55.55600	Replenished	08/22/2023	1002251766	3141657239
False	10033526		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796190	MR00158455	06	07/27/2023	07/27/2023	07/28/2023	62332014231	CELECOXIB 200 MG CAPSULE	200 MG	CAPSULE	100	30	4	13.33300	Replenished	08/22/2023	1002251766	3141657239
False	10028389		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796190	MR00158455	06	07/27/2023	07/27/2023	07/28/2023	62332014231	CELECOXIB 200 MG CAPSULE	200 MG	CAPSULE	100	30	26	86.66700	Replenished	08/22/2023	1002251495	3141657237
False	10010784		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796866	MR00179500	04	07/25/2023	07/25/2023	07/26/2023	62332014231	CELECOXIB 200 MG CAPSULE	200 MG	CAPSULE	100	60	60	100.00000	Replenished	08/22/2023	1002251495	3141657237
False	9953480		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799144	MR00256491	00	07/14/2023	07/14/2023	07/16/2023	62332014231	CELECOXIB 200 MG CAPSULE	200 MG	CAPSULE	100	60	14	23.33300	Replenished	08/22/2023	1002251495	3141657237