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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	2934494		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779179	MR00162256	00	01/13/2021	01/13/2021	01/14/2021	00093720298	PRAVASTATIN SODIUM 40 MG TAB	40 MG	TABLET	90	90	30	33.33300	Replenished		1001796406
False	2934495		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779179	MR00162256	00	01/13/2021	01/13/2021	01/14/2021	00093720298	PRAVASTATIN SODIUM 40 MG TAB	40 MG	TABLET	90	90	60	66.66700	Replenished		1001824882	3049647435
False	3071241		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780444	MR00102464	00	03/10/2021	03/10/2021	03/11/2021	00093720298	PRAVASTATIN SODIUM 40 MG TAB	40 MG	TABLET	90	90	30	33.33300	Replenished		1001824882	3049647435
False	3075275		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780444	MR00102464	00	03/10/2021	03/10/2021	03/11/2021	00093720298	PRAVASTATIN SODIUM 40 MG TAB	40 MG	TABLET	90	90	60	66.66700	Replenished		1001871620	3058108728
False	3719630		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782493	MR00102464	00	06/08/2021	06/08/2021	06/09/2021	00093720298	PRAVASTATIN SODIUM 40 MG TAB	40 MG	TABLET	90	90	30	33.33300	Replenished		1001871620	3058108728
False	3726131		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782493	MR00102464	00	06/08/2021	06/08/2021	06/09/2021	00093720298	PRAVASTATIN SODIUM 40 MG TAB	40 MG	TABLET	90	90	60	66.66700	Replenished		1001921174	3067195910
False	4468005		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784614	MR00102464	00	09/08/2021	09/08/2021	09/09/2021	00093720298	PRAVASTATIN SODIUM 40 MG TAB	40 MG	TABLET	90	90	30	33.33300	Replenished		1001921174	3067195910
False	4475148		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784614	MR00102464	00	09/08/2021	09/08/2021	09/09/2021	00093720298	PRAVASTATIN SODIUM 40 MG TAB	40 MG	TABLET	90	90	60	66.66700	Replenished		1001969736	3076071583
False	5117248		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786716	MR00102464	00	12/06/2021	12/06/2021	12/07/2021	00093720298	PRAVASTATIN SODIUM 40 MG TAB	40 MG	TABLET	90	90	30	33.33300	Replenished		1001969736	3076071583
False	5123544		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786716	MR00102464	00	12/06/2021	12/06/2021	12/07/2021	00093720298	PRAVASTATIN SODIUM 40 MG TAB	40 MG	TABLET	90	90	60	66.66700	Replenished		1002013954	3085324394