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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	9102589		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795982	MR00369135	01	04/03/2023	04/03/2023	04/13/2023	61874013030	VRAYLAR 3 MG CAPSULE	3 MG	CAPSULE	30	30	30	100.00000	Replenished	04/14/2023	1002206646	3130028456