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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	2934560		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779478	MR00177844	00	01/26/2021	01/26/2021	01/27/2021	65162010110	GABAPENTIN 100 MG CAPSULE	100 MG	CAPSULE	100	180	75	41.66700	Replenished		1001802067
False	2934562		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779478	MR00177844	00	01/26/2021	01/26/2021	01/27/2021	65162010110	GABAPENTIN 100 MG CAPSULE	100 MG	CAPSULE	100	180	100	55.55500	Replenished		1001802067
False	8959544		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793961	MR00195463	03	03/28/2023	03/28/2023	03/29/2023	65162010110	GABAPENTIN 100 MG CAPSULE	100 MG	CAPSULE	100	30	10	33.33300	Replenished		1001802067
False	9004079		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795135	MR00041597	03	03/31/2023	03/31/2023	04/01/2023	65162010110	GABAPENTIN 100 MG CAPSULE	100 MG	CAPSULE	100	60	15	25.00000	Replenished		1001802067
False	2934559		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778220	MR00195463	02	02/03/2021	02/03/2021	02/05/2021	65162010110	GABAPENTIN 100 MG CAPSULE	100 MG	CAPSULE	100	90	90	100.00000	Replenished		1001812276	987651857
False	2934561		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779478	MR00177844	00	01/26/2021	01/26/2021	01/27/2021	65162010110	GABAPENTIN 100 MG CAPSULE	100 MG	CAPSULE	100	180	5	2.77800	Replenished		1001812276	987651857
False	2958368		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779839	MR00041597	00	02/17/2021	02/17/2021	02/18/2021	65162010110	GABAPENTIN 100 MG CAPSULE	100 MG	CAPSULE	100	60	5	8.33300	Replenished		1001812276	987651857
False	2961666		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779839	MR00041597	00	02/17/2021	02/17/2021	02/18/2021	65162010110	GABAPENTIN 100 MG CAPSULE	100 MG	CAPSULE	100	60	55	91.66700	Replenished		1001814475	987756775
False	2963033		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779963	MR00177844	00	02/18/2021	02/18/2021	02/19/2021	65162010110	GABAPENTIN 100 MG CAPSULE	100 MG	CAPSULE	100	180	45	25.00000	Replenished		1001814475	987756775
False	2966255		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779963	MR00177844	00	02/18/2021	02/18/2021	02/19/2021	65162010110	GABAPENTIN 100 MG CAPSULE	100 MG	CAPSULE	100	180	100	55.55600	Replenished		1001814475	987756775