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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	4684238		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785322	MR00388862	00	10/06/2021	10/06/2021	10/08/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33300	Replenished		1001958724	3073746995
False	4690793		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785322	MR00388862	00	10/06/2021	10/06/2021	10/08/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33300	Replenished		1001958724	3073746995
False	4690794		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785322	MR00388862	00	10/06/2021	10/06/2021	10/08/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33400	Replenished		1001958724	3073746995
False	4660389		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778084	MR00279358	03	10/04/2021	10/04/2021	10/05/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	30	30	100.00000	Replenished		1001951026	3072312986
False	4628788		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785156	MR00122156	00	09/29/2021	09/29/2021	09/30/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33400	Replenished		1001944297	3070884327
False	4628787		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785156	MR00122156	00	09/29/2021	09/29/2021	09/30/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33300	Replenished		1001938768	3070294281
False	4640890		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778940	MR00179628	09	10/01/2021	10/01/2021	10/02/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	30	30	100.00000	Replenished		1001935094	3069471044
False	4623358		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785156	MR00122156	00	09/29/2021	09/29/2021	09/30/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	90	30	33.33300	Replenished		1001929791	3069291945
False	4548705		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784892	MR00319594	00	09/18/2021	09/18/2021	09/19/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	30	30	100.00000	Replenished		1001924730	3068049382
False	4505286		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778084	MR00279358	02	09/13/2021	09/13/2021	09/14/2021	65862020330	LOSARTAN POTASSIUM 100 MG TAB	100 MG	TABLET	30	30	30	100.00000	Replenished		1001923041	3067590209