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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	6094269		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789561	MR00319594	00	04/14/2022	04/14/2022	04/15/2022	65702072910	ACCU-CHEK GUIDE MONITOR SYSTEM		EACH	1	1	1	100.00000	Replenished		1002036295	3089902768