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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	8598968		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	00	02/16/2023	02/16/2023	02/17/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	4	3.33300	Replenished		1002179601	3123877800
False	10154860		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012820	MR00252736	00	08/14/2023	08/14/2023	08/15/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	56	4	7.14300	Replenished	08/16/2023	1002259761	3143593677
False	9129108		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	02	04/14/2023	04/14/2023	04/15/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	8	6.66700	Replenished	04/17/2023	1002208015	3130202879
False	9133510		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	02	04/14/2023	04/14/2023	04/15/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	12	10.00000	Replenished	05/18/2023	1002221191	3133750054
False	8606067		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	00	02/16/2023	02/16/2023	02/17/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	16	13.33400	Replenished		1002192761	3126917242
False	7250982		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012290	MR00204569	01	09/01/2022	09/01/2022	09/02/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	20	20.00000	Replenished		1002147857	3115655015
False	7470801		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012290	MR00204569	02	10/03/2022	10/03/2022	10/04/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	100	20	20.00000	Replenished		1002147857	3115655015
False	7075309		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012300	MR00252736	00	08/09/2022	08/09/2022	08/10/2022	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	20	33.33300	Replenished		1002100079	3104971540
False	8328092		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012530	MR00252736	00	01/16/2023	01/16/2023	01/17/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	60	20	33.33300	Replenished		1002164575	3120074503
False	9391916		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012564	MR00204569	03	05/15/2023	05/15/2023	05/16/2023	59762371901	ALPRAZOLAM 0.25 MG TABLET	0.25 MG	TABLET	100	120	20	16.66700	Replenished	06/16/2023	1002234551	3136912239