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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	9406094		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796313	MR00109185	00	05/09/2023	05/09/2023	05/17/2023	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	30	33.33300	Replenished	08/16/2023	1002259761	3143593678
False	10100365		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796313	MR00109185	01	08/08/2023	08/08/2023	08/09/2023	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	60	66.66700	Replenished	08/16/2023	1002259761	3143593678
False	8412367		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789252	MR00109185	03	01/25/2023	01/25/2023	01/26/2023	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	30	33.33300	Replenished	05/19/2023	1002221549	3133876132
False	9397910		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796313	MR00109185	00	05/09/2023	05/09/2023	05/17/2023	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	60	66.66700	Replenished	05/19/2023	1002221549	3133876132
False	8405276		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789252	MR00109185	03	01/25/2023	01/25/2023	01/26/2023	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	60	66.66700	Replenished		1002167937	3121218016
False	8367467		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795589	MR00248486	00	01/20/2023	01/20/2023	01/21/2023	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1002167937	3121218016
False	7641273		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789252	MR00109185	02	10/24/2022	10/24/2022	10/25/2022	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	30	33.33300	Replenished		1002149821	3116206380
False	7750783		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793313	MR00248486	01	11/07/2022	11/07/2022	11/08/2022	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1002149821	3116206380
False	8044828		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793313	MR00248486	02	12/12/2022	12/12/2022	12/13/2022	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1002149821	3116206380
False	7636438		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789252	MR00109185	02	10/24/2022	10/24/2022	10/25/2022	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	60	66.66700	Replenished		1002125076	3110431983