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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	3231333		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780924	MR00171522	00	03/31/2021	03/31/2021	04/01/2021	76204060060	IPRAT-ALBUT 0.5-3(2.5) MG/3 ML	0.5-3MG/3	AMPUL-NEB.	180	360	180	50.00000	Replenished		1001835626	3051655272
False	3235257		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780924	MR00171522	00	03/31/2021	03/31/2021	04/01/2021	76204060060	IPRAT-ALBUT 0.5-3(2.5) MG/3 ML	0.5-3MG/3	AMPUL-NEB.	180	360	180	50.00000	Replenished		1001835626	3051655272
False	3470751		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781630	MR00171522	00	05/03/2021	05/03/2021	05/04/2021	76204060060	IPRAT-ALBUT 0.5-3(2.5) MG/3 ML	0.5-3MG/3	AMPUL-NEB.	180	360	180	50.00000	Replenished		1001851763	3054766187
False	3474216		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781630	MR00171522	00	05/03/2021	05/03/2021	05/04/2021	76204060060	IPRAT-ALBUT 0.5-3(2.5) MG/3 ML	0.5-3MG/3	AMPUL-NEB.	180	360	180	50.00000	Replenished		1001851763	3054766187
False	4613845		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785119	MR00038013	00	09/28/2021	09/28/2021	09/29/2021	76204060060	IPRAT-ALBUT 0.5-3(2.5) MG/3 ML	0.5-3MG/3	AMPUL-NEB.	180	360	180	50.00000	Replenished		1001929356	3069158825
False	4620206		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785119	MR00038013	00	09/28/2021	09/28/2021	09/29/2021	76204060060	IPRAT-ALBUT 0.5-3(2.5) MG/3 ML	0.5-3MG/3	AMPUL-NEB.	180	360	180	50.00000	Replenished		1001929356	3069158825
False	5022798		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786469	MR00074834	00	11/23/2021	11/23/2021	11/24/2021	76204060060	IPRAT-ALBUT 0.5-3(2.5) MG/3 ML	0.5-3MG/3	AMPUL-NEB.	180	180	180	100.00000	Replenished		1001963534	3074872858
False	5059653		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786533	MR00038013	00	11/29/2021	11/29/2021	11/30/2021	76204060060	IPRAT-ALBUT 0.5-3(2.5) MG/3 ML	0.5-3MG/3	AMPUL-NEB.	180	360	180	50.00000	Replenished		1001965091	3075301281
False	5063867		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786533	MR00038013	00	11/29/2021	11/29/2021	11/30/2021	76204060060	IPRAT-ALBUT 0.5-3(2.5) MG/3 ML	0.5-3MG/3	AMPUL-NEB.	180	360	180	50.00000	Replenished		1001965091	3075301281
False	5477654		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786533	MR00038013	01	01/24/2022	01/24/2022	01/25/2022	76204060060	IPRAT-ALBUT 0.5-3(2.5) MG/3 ML	0.5-3MG/3	AMPUL-NEB.	180	360	180	50.00000	Replenished		1001994028	3081275297