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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
3823513
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011544
MR00020668
00
06/23/2021
06/23/2021
06/24/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
30
100.00000
Replenished
1001888398
3061086531
False
4147209
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011627
MR00020668
00
07/27/2021
07/27/2021
07/29/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
30
100.00000
Replenished
1001911378
3066004375
False
4387133
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011695
MR00020668
00
08/26/2021
08/26/2021
08/27/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
30
100.00000
Replenished
1001921962
3067326643
False
4613846
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011764
MR00020668
00
09/27/2021
09/27/2021
09/29/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
30
100.00000
Replenished
1001945251
3071148262
False
4835159
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011835
MR00020668
00
10/27/2021
10/27/2021
10/29/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
30
100.00000
Replenished
1001952718
3073037128
False
5059616
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011888
MR00020668
00
11/29/2021
11/29/2021
11/30/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
30
100.00000
Replenished
1001975684
3077386381
False
3080850
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011323
MR00051318
00
03/12/2021
03/12/2021
03/13/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
20
20
100.00000
Replenished
1001826768
3050065355
False
3166420
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011350
MR00051318
00
03/24/2021
03/24/2021
03/25/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
30
30
100.00000
Replenished
1001834470
3051403571
False
3285614
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011382
MR00051318
00
04/09/2021
04/09/2021
04/10/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
20
20
100.00000
Replenished
1001849254
3054056167
False
3426471
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011422
MR00051318
00
04/26/2021
04/26/2021
04/27/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
60
10
16.66700
Replenished
1001849254
3054056167