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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
Memorial Hospital**Trapp Pharmacy (#1)**Trapp Pharmacy (#1)Third Party – Captured 000000780914 MR000122650003/31/202103/31/202104/01/202100069047103CHANTIX STARTING MONTH BOX0.5 (11)-1TAB DS PK535353100.00000Replenished 1001835626 3051655272