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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
2934435
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000776281
MR00387937
04
02/05/2021
02/05/2021
02/06/2021
00003089421
ELIQUIS 5 MG TABLET
5 MG
TABLET
60
60
10
16.66700
Replenished
1001807887
False
2934434
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000779807
MR00170923
00
02/10/2021
02/10/2021
02/11/2021
00003089421
ELIQUIS 5 MG TABLET
5 MG
TABLET
60
60
60
100.00000
Replenished
1001811232
987509358
False
2967708
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000774754
MR00060604
06
02/19/2021
02/19/2021
02/20/2021
00003089421
ELIQUIS 5 MG TABLET
5 MG
TABLET
60
60
10
16.66700
Replenished
1001814818
987756777
False
2934436
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000776281
MR00387937
04
02/05/2021
02/05/2021
02/06/2021
00003089421
ELIQUIS 5 MG TABLET
5 MG
TABLET
60
60
50
83.33300
Replenished
1001814818
987756777
False
2971477
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000774754
MR00060604
06
02/19/2021
02/19/2021
02/20/2021
00003089421
ELIQUIS 5 MG TABLET
5 MG
TABLET
60
60
50
83.33300
Replenished
1001816393
987952822
False
2979711
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000780120
MR00102464
00
02/23/2021
02/23/2021
02/24/2021
00003089421
ELIQUIS 5 MG TABLET
5 MG
TABLET
60
60
10
16.66700
Replenished
1001816393
987952822
False
3033647
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000776281
MR00387937
05
03/03/2021
03/03/2021
03/04/2021
00003089421
ELIQUIS 5 MG TABLET
5 MG
TABLET
60
60
10
16.66700
Replenished
1001821238
3048978888
False
2985840
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000780120
MR00102464
00
02/23/2021
02/23/2021
02/24/2021
00003089421
ELIQUIS 5 MG TABLET
5 MG
TABLET
60
60
50
83.33300
Replenished
1001821238
3048978888
False
3048346
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000780340
MR00377478
00
03/05/2021
03/05/2021
03/05/2021
00003089421
ELIQUIS 5 MG TABLET
5 MG
TABLET
60
60
10
16.66700
Replenished
1001822785
3049139689
False
3039659
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000776281
MR00387937
05
03/03/2021
03/03/2021
03/04/2021
00003089421
ELIQUIS 5 MG TABLET
5 MG
TABLET
60
60
50
83.33300
Replenished
1001822785
3049139689