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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	7725640		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786520	MR00389011	11	11/04/2022	11/04/2022	11/06/2022	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	60	100.00000	Replenished		1002129142	3111671677
False	7458156		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786520	MR00389011	10	10/01/2022	10/01/2022	10/02/2022	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	60	100.00000	Replenished		1002119666	3108617906
False	10052132		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796928	MR00296762	04	07/31/2023	07/31/2023	08/01/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	60	100.00000	Replenished	08/22/2023	1002252361	3141976738
False	7848141		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788476	MR00326153	03	11/17/2022	11/17/2022	11/18/2022	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	180	80	44.44400	Replenished		1002138927	3113726126
False	7841807		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000788476	MR00326153	03	11/17/2022	11/17/2022	11/18/2022	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	180	100	55.55600	Replenished		1002137601	3113250051
False	9774909		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796928	MR00296762	03	06/24/2023	06/24/2023	06/25/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	60	100.00000	Replenished	08/22/2023	1002240777	3139104980
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	8493340		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794588	MR00389011	02	02/03/2023	02/03/2023	02/04/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	20	33.33300	Replenished		1002178976	3123538684
False	8485419		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794588	MR00389011	02	02/03/2023	02/03/2023	02/04/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	40	66.66700	Replenished		1002170585	3122206860