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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
5054183
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011614
MR00195562
03
11/27/2021
11/27/2021
11/28/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
21
70.00000
Replenished
1001975684
3077386381
False
5059616
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011888
MR00020668
00
11/29/2021
11/29/2021
11/30/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
30
100.00000
Replenished
1001975684
3077386381
False
5096646
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011900
MR00206514
00
12/03/2021
12/03/2021
12/04/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
45
100.00000
Replenished
1001975684
3077386381
False
5210204
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011925
MR00310337
00
12/17/2021
12/17/2021
12/18/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
4
13.33300
Replenished
1001975684
3077386381
False
5051611
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011614
MR00195562
03
11/27/2021
11/27/2021
11/28/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
9
30.00000
Replenished
1001964634
3075007286
False
4889093
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011850
MR00283017
00
11/04/2021
11/04/2021
11/05/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
40
31
77.50000
Replenished
1001964634
3075007286
False
5015894
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011877
MR00283017
00
11/22/2021
11/22/2021
11/23/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
60
60
100.00000
Replenished
1001964634
3075007286
False
4764915
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011614
MR00195562
02
10/18/2021
10/18/2021
10/19/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
16
53.33300
Replenished
1001952718
3073037128
False
4783686
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011820
MR00206514
00
10/21/2021
10/21/2021
10/22/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
45
100.00000
Replenished
1001952718
3073037128
False
4835159
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011835
MR00020668
00
10/27/2021
10/27/2021
10/29/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
30
100.00000
Replenished
1001952718
3073037128