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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
10162448
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000798582
MR00158620
02
08/15/2023
08/15/2023
08/16/2023
43547052603
NEBIVOLOL 10 MG TABLET
10 MG
TABLET
30
30
30
100.00000
Replenished
08/23/2023
1002261840
3144399971
False
9962797
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000798582
MR00158620
01
07/18/2023
07/18/2023
07/19/2023
43547052603
NEBIVOLOL 10 MG TABLET
10 MG
TABLET
30
30
30
100.00000
Replenished
08/22/2023
1002248589
3140519199
False
9672400
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000798582
MR00158620
00
06/14/2023
06/14/2023
06/15/2023
43547052603
NEBIVOLOL 10 MG TABLET
10 MG
TABLET
30
30
30
100.00000
Replenished
06/16/2023
1002234551
3136913250
False
9397921
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000796068
MR00158620
02
05/17/2023
05/17/2023
05/18/2023
43547052603
NEBIVOLOL 10 MG TABLET
10 MG
TABLET
30
30
30
100.00000
Replenished
05/19/2023
1002221549
3133876132
False
9148365
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000796068
MR00158620
01
04/17/2023
04/17/2023
04/18/2023
43547052603
NEBIVOLOL 10 MG TABLET
10 MG
TABLET
30
30
30
100.00000
Replenished
04/19/2023
1002208692
3130511160
False
8847882
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000796068
MR00158620
00
03/15/2023
03/15/2023
03/16/2023
43547052603
NEBIVOLOL 10 MG TABLET
10 MG
TABLET
30
30
30
100.00000
Replenished
1002192761
3126917243
False
8574701
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000794662
MR00158620
02
02/13/2023
02/13/2023
02/14/2023
43547052603
NEBIVOLOL 10 MG TABLET
10 MG
TABLET
30
30
30
100.00000
Replenished
1002178681
3123384823
False
8218038
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000794662
MR00158620
01
01/03/2023
01/03/2023
01/04/2023
43547052603
NEBIVOLOL 10 MG TABLET
10 MG
TABLET
30
30
30
100.00000
Replenished
1002171376
3122543058
False
7984559
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000794662
MR00158620
00
12/05/2022
12/06/2022
12/07/2022
43547052603
NEBIVOLOL 10 MG TABLET
10 MG
TABLET
30
30
30
100.00000
Replenished
1002143527
3115279290