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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	4147196		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782680	MR00097732	01	07/15/2021	07/15/2021	07/28/2021	00078069620	ENTRESTO 97 MG-103 MG TABLET	97MG-103MG	TABLET	60	60	60	100.00000	Replenished		1001897770	3062993331
False	4335895		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782680	MR00097732	02	08/12/2021	08/12/2021	08/22/2021	00078069620	ENTRESTO 97 MG-103 MG TABLET	97MG-103MG	TABLET	60	60	60	100.00000	Replenished		1001908104	3065555058
False	4554420		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782680	MR00097732	03	09/14/2021	09/14/2021	09/20/2021	00078069620	ENTRESTO 97 MG-103 MG TABLET	97MG-103MG	TABLET	60	60	60	100.00000	Replenished		1001906780	3065449437
False	4738373		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782680	MR00097732	04	10/13/2021	10/13/2021	10/15/2021	00078069620	ENTRESTO 97 MG-103 MG TABLET	97MG-103MG	TABLET	60	60	60	100.00000	Replenished		1001906780	3065449437
False	4939219		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782680	MR00097732	05	11/10/2021	11/10/2021	11/12/2021	00078069620	ENTRESTO 97 MG-103 MG TABLET	97MG-103MG	TABLET	60	60	60	100.00000	Replenished		1001958160	3073746994
False	5181552		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782680	MR00097732	06	12/13/2021	12/13/2021	12/15/2021	00078069620	ENTRESTO 97 MG-103 MG TABLET	97MG-103MG	TABLET	60	60	60	100.00000	Replenished		1001974055	3077028456
False	5405129		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782680	MR00097732	07	01/12/2022	01/12/2022	01/14/2022	00078069620	ENTRESTO 97 MG-103 MG TABLET	97MG-103MG	TABLET	60	60	60	100.00000	Replenished		1001993531	3080996429
False	5623115		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782680	MR00097732	08	02/10/2022	02/10/2022	02/12/2022	00078069620	ENTRESTO 97 MG-103 MG TABLET	97MG-103MG	TABLET	60	60	60	100.00000	Replenished		1002004973	3083258060
False	5843264		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782680	MR00097732	09	03/11/2022	03/11/2022	03/13/2022	00078069620	ENTRESTO 97 MG-103 MG TABLET	97MG-103MG	TABLET	60	60	60	100.00000	Replenished		1002018687	3086273043
False	6102418		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782680	MR00097732	10	04/14/2022	04/14/2022	04/16/2022	00078069620	ENTRESTO 97 MG-103 MG TABLET	97MG-103MG	TABLET	60	60	60	100.00000	Replenished		1002036633	3089903741