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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	9562798		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798318	MR00259860	00	06/01/2023	06/01/2023	06/03/2023	00527328646	LEVOTHYROXINE 125 MCG TABLET	125 MCG	TABLET	90	90	50	55.55600	Replenished	06/05/2023	1002226579	3135522748
False	9423136		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794005	MR00395196	06	05/19/2023	05/19/2023	05/20/2023	00527328646	LEVOTHYROXINE 125 MCG TABLET	125 MCG	TABLET	90	30	30	100.00000	Replenished	06/05/2023	1002226579	3135522748
False	9179298		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794005	MR00395196	05	04/20/2023	04/20/2023	04/21/2023	00527328646	LEVOTHYROXINE 125 MCG TABLET	125 MCG	TABLET	90	30	10	33.33300	Replenished	06/05/2023	1002226579	3135522748
False	9174102		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794005	MR00395196	05	04/20/2023	04/20/2023	04/21/2023	00527328646	LEVOTHYROXINE 125 MCG TABLET	125 MCG	TABLET	90	30	20	66.66700	Replenished	04/21/2023	1001798519
False	8885356		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794005	MR00395196	04	03/20/2023	03/20/2023	03/21/2023	00527328646	LEVOTHYROXINE 125 MCG TABLET	125 MCG	TABLET	90	30	30	100.00000	Replenished		1001798519
False	8663271		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794510	MR00259860	01	02/23/2023	02/23/2023	02/24/2023	00527328646	LEVOTHYROXINE 125 MCG TABLET	125 MCG	TABLET	90	90	40	44.44400	Replenished		1001798519
False	8657233		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794510	MR00259860	01	02/23/2023	02/23/2023	02/24/2023	00527328646	LEVOTHYROXINE 125 MCG TABLET	125 MCG	TABLET	90	90	50	55.55600	Replenished		1002181581	3124681384
False	8647147		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795118	MR00068492	02	02/22/2023	02/22/2023	02/23/2023	00527328646	LEVOTHYROXINE 125 MCG TABLET	125 MCG	TABLET	90	30	30	100.00000	Replenished		1002181581	3124681384
False	8644183		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794005	MR00395196	03	02/20/2023	02/20/2023	02/21/2023	00527328646	LEVOTHYROXINE 125 MCG TABLET	125 MCG	TABLET	90	30	10	33.33300	Replenished		1002181581	3124681384
False	8637239		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794005	MR00395196	03	02/20/2023	02/20/2023	02/21/2023	00527328646	LEVOTHYROXINE 125 MCG TABLET	125 MCG	TABLET	90	30	20	66.66700	Replenished		1002180956	3124348932