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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	6066726		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781652	MR00316314	10	04/11/2022	04/11/2022	04/12/2022	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1002033642	3089441266
False	5858547		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781652	MR00316314	09	03/14/2022	03/14/2022	03/16/2022	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1002027177	3088118830
False	5623090		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781652	MR00316314	08	02/11/2022	02/11/2022	02/12/2022	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1002012950	3084815368
False	5405139		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781652	MR00316314	07	01/13/2022	01/13/2022	01/14/2022	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001989515	3080235784
False	5199403		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781652	MR00316314	06	12/16/2021	12/16/2021	12/17/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001989515	3080235784
False	4824135		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781652	MR00316314	05	10/27/2021	10/27/2021	10/28/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001962155	3074468468
False	4613834		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781652	MR00316314	04	09/28/2021	09/28/2021	09/29/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001929356	3069158825
False	6036045		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785455	MR00248486	04	04/06/2022	04/06/2022	04/07/2022	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1002033642	3089441266
False	3020616		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776817	MR00316314	03	03/01/2021	03/01/2021	03/02/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001835626	3051655272
False	4363048		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781652	MR00316314	03	08/25/2021	08/25/2021	08/26/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001923771	3067867836