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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	9209545		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793802	MR00067064	02	04/24/2023	04/24/2023	04/25/2023	00378180977	LEVOTHYROXINE 100 MCG TABLET	100 MCG	TABLET	90	90	90	100.00000	Replenished	05/02/2023	1002210717	3131427601