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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	7513125		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789871	MR00082070	02	10/08/2022	10/08/2022	10/09/2022	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	90	10	11.11100	Replenished		1002119666	3108617906
False	7517879		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789871	MR00082070	02	10/08/2022	10/08/2022	10/09/2022	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	90	80	88.88900	Replenished		1002124663	3110135018
False	8395379		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795665	MR00082070	00	01/24/2023	01/24/2023	01/25/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	90	90	100.00000	Replenished		1002167601	3121067798
False	9059611		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797166	MR00082070	00	04/06/2023	04/06/2023	04/07/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	90	20	22.22300	Replenished	05/08/2023	1002213772	3132524754
False	9051450		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797166	MR00082070	00	04/06/2023	04/06/2023	04/07/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	90	30	33.33300	Replenished		1002199438	3129427833
False	9059610		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797166	MR00082070	00	04/06/2023	04/06/2023	04/07/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	90	40	44.44400	Replenished		1002199438	3129427833
False	9880174		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799010	MR00082070	00	07/06/2023	07/06/2023	07/07/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	90	40	44.44400	Replenished	08/22/2023	1002252361	3141976738
False	9873267		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000799010	MR00082070	00	07/06/2023	07/06/2023	07/07/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	90	50	55.55600	Replenished	08/22/2023	1002244869	3139279459
False	7667182		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793815	MR00223267	00	10/27/2022	10/27/2022	10/28/2022	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	30	30	100.00000	Replenished		1002129142	3111671677
False	7391525		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793024	MR00279358	00	09/22/2022	09/22/2022	09/23/2022	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	30	30	100.00000	Replenished		1002119666	3108617906