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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	2933828		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000775745	MR00289972	00	11/14/2020	11/14/2020	11/15/2020	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	360	100	27.77700	Replenished		1001765042
False	2933829		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000775745	MR00289972	00	11/14/2020	11/14/2020	11/15/2020	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	360	100	27.77800	Replenished		1001765042
False	2933830		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000775745	MR00289972	00	11/14/2020	11/14/2020	11/15/2020	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	360	100	27.77800	Replenished		1001765042
False	7068454		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792016	MR00117446	00	08/09/2022	08/09/2022	08/10/2022	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	90	100.00000	Replenished		1002102296	3105614642
False	8395410		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793575	MR00117446	03	01/24/2023	01/24/2023	01/25/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	90	100.00000	Replenished		1002167601	3121067798
False	9166408		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793575	MR00117446	05	04/19/2023	04/19/2023	04/20/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	90	100.00000	Replenished	05/08/2023	1002213418	3132524753
False	8552498		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795930	MR00157951	00	02/06/2023	02/06/2023	02/11/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	90	100.00000	Replenished		1002182991	3124681387
False	9081904		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797212	MR00157951	00	04/10/2023	04/10/2023	04/11/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	90	100.00000	Replenished	04/12/2023	1002200467	3129734792
False	7282278		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792706	MR00117446	00	09/06/2022	09/06/2022	09/09/2022	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	80	88.88900	Replenished		1002114625	3108158138
False	8689599		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793575	MR00117446	04	02/21/2023	02/21/2023	02/25/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	80	88.88900	Replenished		1002186410	3126119732