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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
7187606
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012090
MR00030919
05
08/23/2022
08/23/2022
08/25/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
1
3.33300
Replenished
1002152667
3117383034
False
7172230
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012090
MR00030919
05
08/23/2022
08/23/2022
08/25/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
29
96.66700
Replenished
1002096808
3104187392
False
8682286
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012373
MR00030919
05
02/21/2023
02/21/2023
02/25/2023
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
30
100.00000
Replenished
1002195747
3128183149
False
6912744
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012090
MR00030919
04
07/18/2022
07/18/2022
07/19/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
30
100.00000
Replenished
1002096808
3104187392
False
8405247
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012373
MR00030919
04
01/25/2023
01/25/2023
01/26/2023
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
30
100.00000
Replenished
1002195747
3128183149
False
6646533
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012090
MR00030919
03
06/21/2022
06/21/2022
06/22/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
30
100.00000
Replenished
1002096808
3104187392
False
8139088
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012373
MR00030919
03
12/23/2022
12/23/2022
12/24/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
4
13.33300
Replenished
1002152667
3117383034
False
8144194
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012373
MR00030919
03
12/23/2022
12/23/2022
12/24/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
26
86.66700
Replenished
1002195747
3128183149
False
9803654
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012620
MR00030919
03
06/28/2023
06/28/2023
06/29/2023
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
24
80.00000
Replenished
06/30/2023
1002238934
3138442988
False
6349333
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012090
MR00030919
02
05/18/2022
05/18/2022
05/19/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
11
36.66700
Replenished
1002096808
3104187392