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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	6259249		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790082	MR00046140	00	05/06/2022	05/06/2022	05/07/2022	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	10	10	100.00000	Replenished		1002079621	3099252329
False	6334379		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790282	MR00018205	00	05/17/2022	05/17/2022	05/18/2022	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	6	6	100.00000	Replenished		1002079621	3099252329
False	6334384		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790297	MR00233748	00	05/17/2022	05/17/2022	05/18/2022	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	10	10	100.00000	Replenished		1002079621	3099252329
False	6429611		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790575	MR00218418	00	05/31/2022	05/31/2022	06/01/2022	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	14	14	100.00000	Replenished		1002079621	3099252329
False	6429576		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790595	MR00208636	00	05/31/2022	05/31/2022	06/01/2022	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	14	14	100.00000	Replenished		1002079621	3099252329
False	6505411		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790792	MR00195562	00	06/09/2022	06/09/2022	06/10/2022	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	10	10	100.00000	Replenished		1002079621	3099252329
False	6545415		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790924	MR00064924	00	06/15/2022	06/15/2022	06/16/2022	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	10	10	100.00000	Replenished		1002079621	3099252329
False	6561291		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790982	MR00313919	00	06/17/2022	06/17/2022	06/18/2022	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	14	14	100.00000	Replenished		1002079621	3099252329
False	6871629		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791458	MR00025513	00	07/12/2022	07/12/2022	07/13/2022	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	14	2	14.28600	Replenished		1002168256	3121399107
False	6863232		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791458	MR00025513	00	07/12/2022	07/12/2022	07/13/2022	00143992801	CIPROFLOXACIN HCL 500 MG TAB	500 MG	TABLET	100	14	12	85.71400	Replenished		1002079621	3099252329