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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	9406094		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796313	MR00109185	00	05/09/2023	05/09/2023	05/17/2023	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	30	33.33300	Replenished	08/16/2023	1002259761	3143593678
False	10100365		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796313	MR00109185	01	08/08/2023	08/08/2023	08/09/2023	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	60	66.66700	Replenished	08/16/2023	1002259761	3143593678
False	8412367		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789252	MR00109185	03	01/25/2023	01/25/2023	01/26/2023	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	30	33.33300	Replenished	05/19/2023	1002221549	3133876132
False	9397910		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796313	MR00109185	00	05/09/2023	05/09/2023	05/17/2023	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	60	66.66700	Replenished	05/19/2023	1002221549	3133876132
False	2933815		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776817	MR00316314	01	11/12/2020	11/12/2020	11/13/2020	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001811232	987509358
False	2933814		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776817	MR00316314	02	02/01/2021	02/01/2021	02/02/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001811232	987509358
False	3020616		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776817	MR00316314	03	03/01/2021	03/01/2021	03/02/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001835626	3051655272
False	2933813		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779884	MR00389011	00	02/12/2021	02/12/2021	02/13/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001811232	987509358
False	3048376		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779884	MR00389011	01	03/05/2021	03/05/2021	03/06/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	30	30	100.00000	Replenished		1001835626	3051655272
False	3020595		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780252	MR00109185	00	03/01/2021	03/01/2021	03/02/2021	00527328846	LEVOTHYROXINE 150 MCG TABLET	150 MCG	TABLET	90	90	90	100.00000	Replenished		1001819373	988099025