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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	4495402		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776362	MR00151354	01	09/11/2021	09/11/2021	09/12/2021	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1001922571	3067326647
False	3433629		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781511	MR00218418	00	04/27/2021	04/27/2021	04/28/2021	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1001849752	3054181639
False	4859357		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781511	MR00218418	01	11/01/2021	11/01/2021	11/02/2021	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1001951777	3072578295
False	4228203		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781578	MR00392804	02	08/09/2021	08/09/2021	08/10/2021	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1001902393	3064140711
False	4458954		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781578	MR00392804	03	09/07/2021	09/07/2021	09/08/2021	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1001919113	3067013098
False	4660388		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781578	MR00392804	04	10/04/2021	10/04/2021	10/05/2021	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1001935866	3069727219
False	4865110		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781578	MR00392804	05	11/02/2021	11/02/2021	11/03/2021	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1001952043	3072719019
False	5505418		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781578	MR00392804	06	01/26/2022	01/26/2022	01/27/2022	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1001995827	3081761726
False	3671909		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782318	MR00210929	00	06/01/2021	06/01/2021	06/02/2021	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1001867724	3057523425
False	3996532		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782318	MR00210929	01	07/07/2021	07/07/2021	07/08/2021	68180096301	ALBUTEROL HFA 90 MCG INHALER	90 MCG	HFA AER AD	8.5	8.5	8.5	100.00000	Replenished		1001891373	3062039555