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Health Center:
Memorial Hospital
Pharmacy:
Trapp Pharmacy (#1)
Capture Date :
To:
Fetching results...
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
5944856
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000789191
MR00043501
00
03/25/2022
03/25/2022
03/26/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
1002045985
3091824990
False
6395786
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000790462
MR00043501
00
05/25/2022
05/25/2022
05/26/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
1002075849
3098184654
False
6987275
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000791836
MR00043501
00
07/28/2022
07/28/2022
07/29/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
1002085352
3101083317
False
7245385
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000791836
MR00043501
01
09/01/2022
09/01/2022
09/02/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
1002113582
3107872087
False
7725582
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000793201
MR00043501
01
11/03/2022
11/03/2022
11/05/2022
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
1002142782
3114755273
False
8187314
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000794587
MR00043501
01
12/30/2022
12/30/2022
01/01/2023
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
1002155556
3118088750
False
8485457
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000795882
MR00043501
00
02/03/2023
02/03/2023
02/04/2023
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
1002185583
3125815325
False
9035410
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000797116
MR00043501
00
04/04/2023
04/04/2023
04/05/2023
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
05/08/2023
1002213418
3132524753
False
9595275
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000798407
MR00043501
00
06/06/2023
06/06/2023
06/07/2023
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
06/08/2023
1002227496
3135977002
False
9873269
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000798994
MR00043501
00
07/06/2023
07/06/2023
07/07/2023
00591534701
PROBENECID 500 MG TABLET
500 MG
TABLET
100
60
60
100.00000
Replenished
08/22/2023
1002253366
3142468423