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Accumulator - View By Claim

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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	6070348		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012112	MR00025513	00	04/11/2022	04/11/2022	04/12/2022	00406048401	ACETAMINOPHEN-COD #3 TABLET	300MG-30MG	TABLET	100	40	30	75.00000	Replenished		1002125076	3110431982
False	6782500		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012243	MR00025513	00	07/01/2022	07/01/2022	07/02/2022	00406048401	ACETAMINOPHEN-COD #3 TABLET	300MG-30MG	TABLET	100	40	40	100.00000	Replenished		1002125076	3110431982
False	7636480		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012406	MR00025513	00	10/24/2022	10/24/2022	10/25/2022	00406048401	ACETAMINOPHEN-COD #3 TABLET	300MG-30MG	TABLET	100	40	30	75.00000	Replenished		1002125076	3110431982
False	4764914		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011810	1882	00	10/18/2021	10/18/2021	10/19/2021	00406048401	ACETAMINOPHEN-COD #3 TABLET	300MG-30MG	TABLET	100	90	10	11.11100	Replenished		1002033642	3089441265
False	4774815		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011815	MR00025513	00	10/19/2021	10/19/2021	10/20/2021	00406048401	ACETAMINOPHEN-COD #3 TABLET	300MG-30MG	TABLET	100	40	40	100.00000	Replenished		1002033642	3089441265
False	5363256		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011966	MR00025513	00	01/07/2022	01/07/2022	01/08/2022	00406048401	ACETAMINOPHEN-COD #3 TABLET	300MG-30MG	TABLET	100	40	40	100.00000	Replenished		1002033642	3089441265
False	6066737		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012112	MR00025513	00	04/11/2022	04/11/2022	04/12/2022	00406048401	ACETAMINOPHEN-COD #3 TABLET	300MG-30MG	TABLET	100	40	10	25.00000	Replenished		1002033642	3089441265
False	4610553		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011763	1882	00	09/27/2021	09/27/2021	09/28/2021	00406048401	ACETAMINOPHEN-COD #3 TABLET	300MG-30MG	TABLET	100	90	20	22.22200	Replenished		1001945251	3071148262
False	4761402		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011810	1882	00	10/18/2021	10/18/2021	10/19/2021	00406048401	ACETAMINOPHEN-COD #3 TABLET	300MG-30MG	TABLET	100	90	80	88.88900	Replenished		1001945251	3071148262
False	4436426		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004011710	1882	00	09/02/2021	09/02/2021	09/03/2021	00406048401	ACETAMINOPHEN-COD #3 TABLET	300MG-30MG	TABLET	100	90	30	33.33300	Replenished		1001928804	3069023027