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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	8997173		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794623	MR00195463	03	03/04/2023	03/04/2023	03/05/2023	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	30	10	33.33300	Replenished	06/05/2023	1002226246	3135522746
False	9051453		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794623	MR00195463	04	04/06/2023	04/06/2023	04/07/2023	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	30	30	100.00000	Replenished	06/05/2023	1002226246	3135522746
False	9276472		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794623	MR00195463	05	05/01/2023	05/01/2023	05/04/2023	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	30	30	100.00000	Replenished	06/05/2023	1002226246	3135522746
False	9544243		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794623	MR00195463	06	05/30/2023	05/30/2023	06/01/2023	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	30	30	100.00000	Replenished	06/05/2023	1002226246	3135522746
False	2933784		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778177	MR00198270	01	12/29/2020	12/29/2020	12/30/2020	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	60	10	16.66700	Replenished		1001816771	988000091
False	2933783		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778177	MR00198270	01	12/29/2020	12/29/2020	12/30/2020	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	60	50	83.33300	Replenished		1001787168
False	2933782		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779509	MR00198270	00	01/28/2021	01/28/2021	01/29/2021	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	60	60	100.00000	Replenished		1001816771	988000091
False	2988205		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780149	MR00198270	00	02/24/2021	02/24/2021	02/25/2021	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	60	30	50.00000	Replenished		1001816771	988000091
False	2994187		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780149	MR00198270	00	02/24/2021	02/24/2021	02/25/2021	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	60	30	50.00000	Replenished		1001854421	3055134799
False	3260677		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780149	MR00198270	01	04/06/2021	04/06/2021	04/07/2021	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	60	60	100.00000	Replenished		1001854421	3055134799