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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
4147214
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000783641
MR00030201
00
07/28/2021
07/28/2021
07/28/2021
00071036924
DILANTIN 100 MG CAPSULE
100 MG
CAPSULE
100
360
40
11.11100
Replenished
1001897770
3062993331
False
4153940
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000783641
MR00030201
00
07/28/2021
07/28/2021
07/28/2021
00071036924
DILANTIN 100 MG CAPSULE
100 MG
CAPSULE
100
360
100
27.77800
Replenished
1001897770
3062993331
False
4153941
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000783641
MR00030201
00
07/28/2021
07/28/2021
07/28/2021
00071036924
DILANTIN 100 MG CAPSULE
100 MG
CAPSULE
100
360
100
27.77800
Replenished
1001897770
3062993331
False
4153942
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000783641
MR00030201
00
07/28/2021
07/28/2021
07/28/2021
00071036924
DILANTIN 100 MG CAPSULE
100 MG
CAPSULE
100
360
100
27.77800
Replenished
1001897770
3062993331
False
3410217
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000779396
MR00030201
00
04/22/2021
04/22/2021
04/22/2021
00071036924
DILANTIN 100 MG CAPSULE
100 MG
CAPSULE
100
360
60
16.66600
Replenished
1001897770
3062993331
False
3403013
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000779396
MR00030201
00
04/22/2021
04/22/2021
04/22/2021
00071036924
DILANTIN 100 MG CAPSULE
100 MG
CAPSULE
100
360
100
27.77800
Replenished
1001847629
3053810031
False
3410215
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000779396
MR00030201
00
04/22/2021
04/22/2021
04/22/2021
00071036924
DILANTIN 100 MG CAPSULE
100 MG
CAPSULE
100
360
100
27.77800
Replenished
1001847629
3053810031
False
3410216
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000779396
MR00030201
00
04/22/2021
04/22/2021
04/22/2021
00071036924
DILANTIN 100 MG CAPSULE
100 MG
CAPSULE
100
360
100
27.77800
Replenished
1001847629
3053810031