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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
2934497
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011172
MR00206514
00
01/04/2021
01/04/2021
01/05/2021
69315090401
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
30
100.00000
Replenished
1001849752
3054181638
False
2948700
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011259
MR00389502
00
02/15/2021
02/15/2021
02/16/2021
69315090401
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
10
10
100.00000
Replenished
1001849752
3054181638
False
3350515
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011396
MR00283017
00
04/15/2021
04/15/2021
04/16/2021
69315090401
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
40
40
100.00000
Replenished
1001849752
3054181638
False
3433654
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011424
BA76RRTH2GDY
00
04/27/2021
04/27/2021
04/28/2021
69315090401
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
20
20
100.00000
Replenished
1001849752
3054181638
False
9610749
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012679
MR00361460
01
06/07/2023
06/07/2023
06/08/2023
69315090401
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
60
7
11.66700
Replenished
06/09/2023
1002231800
3136126191
False
9423133
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012696
MR00368660
00
05/19/2023
05/19/2023
05/20/2023
69315090401
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
30
100.00000
Replenished
06/09/2023
1002231800
3136126191
False
9470457
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012706
MR00154246
00
05/24/2023
05/24/2023
05/25/2023
69315090401
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
3
3
100.00000
Replenished
06/09/2023
1002231800
3136126191
False
9544256
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012719
MR00283017
00
05/31/2023
05/31/2023
06/01/2023
69315090401
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
60
60
100.00000
Replenished
06/09/2023
1002231800
3136126191
False
9616450
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012679
MR00361460
01
06/07/2023
06/07/2023
06/08/2023
69315090401
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
60
53
88.33300
Replenished
06/12/2023
1002232051
3136303174
False
9621081
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012728
MR00206514
00
06/08/2023
06/08/2023
06/09/2023
69315090401
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
27
60.00000
Replenished
06/12/2023
1002232051
3136303174