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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	6904482		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791551	MR00230427	00	07/15/2022	07/15/2022	07/16/2022	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	60	4	6.66700	Replenished		1002097780	3104187395
False	4458919		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784582	MR00210929	00	09/07/2021	09/07/2021	09/08/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	6	6.66700	Replenished		1001919113	3067013098
False	7194606		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792438	MR00041824	00	08/25/2022	08/25/2022	08/26/2022	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	6	6.66700	Replenished		1002097780	3104187395
False	2934507		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774988	MR00210929	02	01/27/2021	01/27/2021	01/28/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	10	11.11100	Replenished		1001802698
False	2951904		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000774988	MR00210929	02	01/27/2021	01/27/2021	01/28/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	10	11.11100	Replenished		1001825446	3049810902
False	3729044		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780459	MR00041824	01	06/09/2021	06/09/2021	06/10/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	10	11.11100	Replenished		1001872170	3058237732
False	4462880		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784582	MR00210929	00	09/07/2021	09/07/2021	09/08/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	10	11.11100	Replenished		1001919113	3067013098
False	4086983		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783447	MR00161301	00	07/20/2021	07/20/2021	07/21/2021	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	14	14	100.00000	Replenished		1001919113	3067013098
False	5758639		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788656	MR00041824	00	03/02/2022	03/02/2022	03/03/2022	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	16	17.77800	Replenished		1002013954	3085324394
False	7286275		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792773	MR00210929	00	09/08/2022	09/08/2022	09/10/2022	16729017101	AMITRIPTYLINE HCL 10 MG TAB	10 MG	TABLET	100	90	16	17.77800	Replenished		1002102488	3105614645