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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	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	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	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	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	8750826		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	20	66.66700	Replenished		1001787168
False	8475163		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794623	MR00195463	02	02/01/2023	02/01/2023	02/02/2023	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	30	30	100.00000	Replenished		1001787168
False	8156709		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794623	MR00195463	01	12/27/2022	12/27/2022	12/28/2022	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	30	30	100.00000	Replenished		1002154521	3117768446
False	7951589		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794623	MR00195463	00	12/02/2022	12/02/2022	12/03/2022	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	30	30	100.00000	Replenished		1002154521	3117768446
False	7761429		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794059	MR00195463	00	11/08/2022	11/08/2022	11/09/2022	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	30	30	100.00000	Replenished		1002154521	3117768446
False	7474277		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792745	MR00195463	01	10/03/2022	10/03/2022	10/04/2022	51672403901	ENALAPRIL MALEATE 10 MG TAB	10 MG	TABLET	100	30	10	33.33300	Replenished		1002154521	3117768446