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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	3280661		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000773469	MR00326153	10	04/08/2021	04/08/2021	04/09/2021	69315011601	FUROSEMIDE 20 MG TABLET	20 MG	TABLET	100	60	1	1.66700	Replenished		1001839679	3052473904
False	3519896		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779621	BBG9FRG6YEC4	03	05/10/2021	05/10/2021	05/11/2021	69315011601	FUROSEMIDE 20 MG TABLET	20 MG	TABLET	100	30	1	3.33300	Replenished		1001856282	3055381317
False	8065918		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000791634	MR00313919	03	12/13/2022	12/13/2022	12/15/2022	69315011601	FUROSEMIDE 20 MG TABLET	20 MG	TABLET	100	30	1	3.33300	Replenished		1002150356	3116568459
False	7588110		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793576	MR00117446	00	10/18/2022	10/18/2022	10/19/2022	69315011601	FUROSEMIDE 20 MG TABLET	20 MG	TABLET	100	120	1	0.83300	Replenished		1002123446	3109811595
False	7871569		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794007	MR00395196	00	11/21/2022	11/21/2022	11/22/2022	69315011601	FUROSEMIDE 20 MG TABLET	20 MG	TABLET	100	30	1	3.33300	Replenished		1002138660	3113575596
False	8102609		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794863	MR00072992	00	12/19/2022	12/19/2022	12/20/2022	69315011601	FUROSEMIDE 20 MG TABLET	20 MG	TABLET	100	90	1	1.11100	Replenished		1002151463	3116913607
False	8240976		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795291	MR00095217	00	01/05/2023	01/05/2023	01/06/2023	69315011601	FUROSEMIDE 20 MG TABLET	20 MG	TABLET	100	180	1	0.55600	Replenished		1002160851	3118886767
False	9938900		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797209	MR00279837	03	07/12/2023	07/12/2023	07/13/2023	69315011601	FUROSEMIDE 20 MG TABLET	20 MG	TABLET	100	30	1	3.33300	Replenished	08/22/2023	1002247993	3140061854
False	9960597		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797287	MR00393085	00	07/17/2023	07/17/2023	07/18/2023	69315011601	FUROSEMIDE 20 MG TABLET	20 MG	TABLET	100	90	1	1.11100	Replenished	08/22/2023	1002252361	3141976738
False	9391939		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797883	MR00296590	00	05/11/2023	05/11/2023	05/16/2023	69315011601	FUROSEMIDE 20 MG TABLET	20 MG	TABLET	100	14	1	7.14300	Replenished	05/19/2023	1002221549	3133876132