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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	2934360		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000778985	450	01	02/08/2021	02/08/2021	02/08/2021	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1001811232	987509358
False	2948698		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000779900	MR00182534	00	02/15/2021	02/15/2021	02/15/2021	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1001811232	987509358
False	2958376		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000779959	MR00037445	00	02/17/2021	02/17/2021	02/17/2021	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1001812276	987651857
False	3048356		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000778294	MR00177615	01	03/05/2021	03/05/2021	03/05/2021	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	90	30	33.33300	Replenished		1001822785	3049139689
False	3052155		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000778294	MR00177615	01	03/05/2021	03/05/2021	03/05/2021	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	90	30	33.33300	Replenished		1001822785	3049139689
False	3052156		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000778294	MR00177615	01	03/05/2021	03/05/2021	03/05/2021	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	90	30	33.33400	Replenished		1001822785	3049139689
False	3110953		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000780562	MR00182534	00	03/15/2021	03/15/2021	03/15/2021	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1001826768	3050065356
False	3151674		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000780670	MR00037445	00	03/22/2021	03/22/2021	03/22/2021	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1001830087	3050733659
False	3301337		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000781177	MR00182534	00	04/12/2021	04/12/2021	04/12/2021	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1001842172	3052723058
False	3378834		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Cash 340B	000000781305	MR00037445	00	04/19/2021	04/19/2021	04/19/2021	50458057930	XARELTO 20 MG TABLET	20 MG	TABLET	30	30	30	100.00000	Replenished		1001845547	3053392934