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Health Center:

Pharmacy:

Capture Date :

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			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	3151656		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780694	MR00160846	00	03/22/2021	03/22/2021	03/23/2021	68462043890	OLMESARTAN MEDOXOMIL 40 MG TAB	40 MG	TABLET	90	90	90	100.00000	Replenished		1001830087	3050733659