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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	2933844		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011144	MR00252736	00	12/21/2020	12/21/2020	12/22/2020	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	20	33.33300	Replenished		1001781752
False	2933845		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011144	MR00252736	00	12/21/2020	12/21/2020	12/22/2020	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	40	66.66700	Replenished		1001819785	3048855807
False	3026226		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011302	MR00252736	00	03/02/2021	03/02/2021	03/03/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	60	100.00000	Replenished		1001819785	3048855807
False	3089818		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011321	MR00204569	00	03/13/2021	03/13/2021	03/14/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	100	100.00000	Replenished		1001826371	3049810905
False	3260707		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011376	MR00252736	00	04/06/2021	04/06/2021	04/07/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	60	100.00000	Replenished		1001842172	3052723057
False	3301334		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011385	MR00204569	00	04/12/2021	04/12/2021	04/13/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	40	40.00000	Replenished		1001842172	3052723057
False	3304892		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011385	MR00204569	00	04/12/2021	04/12/2021	04/13/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	60	60.00000	Replenished		1001856282	3055381316
False	3519930		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011453	MR00252736	00	05/10/2021	05/10/2021	05/11/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	40	66.66700	Replenished		1001856282	3055381316
False	3523128		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011453	MR00252736	00	05/10/2021	05/10/2021	05/11/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	20	33.33300	Replenished		1001857662	3055508680
False	3527653		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011456	MR00204569	00	05/11/2021	05/11/2021	05/12/2021	51991070401	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	80	80.00000	Replenished		1001857662	3055508680