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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	5299037		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787285	MR00250558	00	12/29/2021	12/29/2021	12/30/2021	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	180	100	55.55600	Replenished		1001982259	3078646785
False	6790472		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791267	MR00101113	00	07/01/2022	07/01/2022	07/02/2022	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	180	100	55.55600	Replenished		1002075849	3098184654
False	9170882		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797421	MR00126335	00	04/19/2023	04/19/2023	04/20/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	180	100	55.55600	Replenished	04/21/2023	1002209232	3130801353
False	9295701		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797691	MR00209146	00	05/02/2023	05/02/2023	05/04/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	180	100	55.55600	Replenished	05/08/2023	1002213418	3132524753
False	6133308		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787285	MR00250558	01	04/20/2022	04/20/2022	04/21/2022	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	180	91	50.55600	Replenished		1002039367	3090544681
False	8065934		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788962	MR00128572	03	12/14/2022	12/14/2022	12/15/2022	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	180	91	50.55600	Replenished		1002150356	3116568459
False	7646101		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793071	MR00195463	01	10/25/2022	10/25/2022	10/26/2022	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	120	91	75.83300	Replenished		1002125920	3110578457
False	5516922		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785945	MR00174136	01	01/27/2022	01/27/2022	01/28/2022	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	90	90	100.00000	Replenished		1001998721	3082187336
False	9276541		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797635	MR00174136	00	04/28/2023	04/28/2023	05/04/2023	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	90	90	100.00000	Replenished	05/08/2023	1002213418	3132524753
False	7041209		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785945	MR00174136	03	08/03/2022	08/03/2022	08/04/2022	69315011701	FUROSEMIDE 40 MG TABLET	40 MG	TABLET	100	90	89	98.88900	Replenished		1002093542	3102645765