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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	8231144		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795260	MR00014956	00	01/04/2023	01/04/2023	01/05/2023	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1002160525	3118886765
False	8552495		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795927	MR00014956	00	02/06/2023	02/06/2023	02/11/2023	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1002178117	3123055057
False	7528315		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793472	MR00067064	00	10/11/2022	10/11/2022	10/12/2022	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1002120414	3109055000
False	10036280		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793472	MR00067064	01	07/28/2023	07/28/2023	07/29/2023	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished	08/22/2023	1002251766	3141657239
False	8367473		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795603	MR00075707	00	01/20/2023	01/20/2023	01/21/2023	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1002165771	3120576242
False	10028401		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799403	MR00108206	00	07/27/2023	07/27/2023	07/28/2023	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished	08/22/2023	1002251495	3141657237
False	8574691		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796081	MR00126335	00	02/13/2023	02/13/2023	02/14/2023	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1002178681	3123384823
False	4495402		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776362	MR00151354	01	09/11/2021	09/11/2021	09/12/2021	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1001922571	3067326647
False	7278644		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792666	MR00151354	00	09/06/2022	09/06/2022	09/09/2022	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1002102296	3105614642
False	5452726		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000787796	MR00152015	00	01/20/2022	01/20/2022	01/21/2022	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1001992840	3080996426