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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	2934225		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779610	MR00134075	00	02/02/2021	02/02/2021	02/03/2021	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	80	4	5.00000	Replenished		1001830087	3050733659
False	2934224		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779610	MR00134075	00	02/02/2021	02/02/2021	02/03/2021	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	80	76	95.00000	Replenished		1001806279
False	2963013		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779994	12968	00	02/18/2021	02/18/2021	02/19/2021	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	30	100.00000	Replenished		1001830087	3050733659
False	2999030		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780189	MR00018670	00	02/25/2021	02/25/2021	02/26/2021	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	30	100.00000	Replenished		1001830087	3050733659
False	3142215		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780637	MR00127279	00	03/19/2021	03/19/2021	03/20/2021	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	10	10	100.00000	Replenished		1001830087	3050733659
False	3426491		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781480	MR00018670	00	04/26/2021	04/26/2021	04/27/2021	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	30	100.00000	Replenished		1001897048	3062863316
False	3638911		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782229	MR00018670	00	05/26/2021	05/26/2021	05/27/2021	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	30	100.00000	Replenished		1001897048	3062863316
False	3892196		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782962	MR00018670	00	06/29/2021	06/29/2021	06/30/2021	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	30	100.00000	Replenished		1001897048	3062863316
False	4133434		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783617	MR00018670	00	07/27/2021	07/27/2021	07/28/2021	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	6	20.00000	Replenished		1001897048	3062863316
False	4144320		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783617	MR00018670	00	07/27/2021	07/27/2021	07/28/2021	00093171601	WARFARIN SODIUM 4 MG TABLET	4 MG	TABLET	100	30	24	80.00000	Replenished		1001928804	3069023028