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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
8850753
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000794734
MR00060604
01
03/15/2023
03/15/2023
03/16/2023
50742024990
DILTIAZEM 24H ER(CD) 180 MG CP
180 MG
CAP.SR 24H
90
90
30
33.33300
Replenished
1002199438
3129427833
False
8847896
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000794734
MR00060604
01
03/15/2023
03/15/2023
03/16/2023
50742024990
DILTIAZEM 24H ER(CD) 180 MG CP
180 MG
CAP.SR 24H
90
90
60
66.66700
Replenished
1002192761
3126917243
False
8552522
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000795911
MR00074834
00
02/06/2023
02/06/2023
02/11/2023
50742024990
DILTIAZEM 24H ER(CD) 180 MG CP
180 MG
CAP.SR 24H
90
60
60
100.00000
Replenished
1002185583
3125815325
False
8765256
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000795911
MR00074834
01
03/06/2023
03/06/2023
03/07/2023
50742024990
DILTIAZEM 24H ER(CD) 180 MG CP
180 MG
CAP.SR 24H
90
60
30
50.00000
Replenished
1002185583
3125815325
False
8771335
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000795911
MR00074834
01
03/06/2023
03/06/2023
03/07/2023
50742024990
DILTIAZEM 24H ER(CD) 180 MG CP
180 MG
CAP.SR 24H
90
60
30
50.00000
Replenished
1002192761
3126917243
False
9051441
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000795911
MR00074834
02
04/06/2023
04/06/2023
04/07/2023
50742024990
DILTIAZEM 24H ER(CD) 180 MG CP
180 MG
CAP.SR 24H
90
60
60
100.00000
Replenished
1002199438
3129427833
False
9301129
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000795911
MR00074834
03
05/05/2023
05/05/2023
05/06/2023
50742024990
DILTIAZEM 24H ER(CD) 180 MG CP
180 MG
CAP.SR 24H
90
60
60
100.00000
Replenished
06/12/2023
1002232317
3136303176
False
9562789
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000795911
MR00074834
04
06/02/2023
06/02/2023
06/03/2023
50742024990
DILTIAZEM 24H ER(CD) 180 MG CP
180 MG
CAP.SR 24H
90
60
30
50.00000
Replenished
06/12/2023
1002232317
3136303176