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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
2934341
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000779619
MR00283017
00
02/02/2021
02/02/2021
02/03/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
10
5.55600
Replenished
1001811232
987509358
False
2951968
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000779619
MR00283017
00
02/02/2021
02/02/2021
02/03/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
25
13.88800
Replenished
1001811909
987581092
False
2934340
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000779619
MR00283017
00
02/02/2021
02/02/2021
02/03/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
45
25.00000
Replenished
1001806279
False
2934342
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000779619
MR00283017
00
02/02/2021
02/02/2021
02/03/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
100
55.55600
Replenished
1001806279
False
2934339
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000779621
BBG9FRG6YEC4
00
02/04/2021
02/04/2021
02/06/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
30
30
100.00000
Replenished
1001811232
987509358
False
2934338
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000777338
MR00195463
03
02/05/2021
02/05/2021
02/06/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
30
30
100.00000
Replenished
1001811232
987509358
False
2934337
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000778496
MR00097732
02
02/09/2021
02/09/2021
02/10/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
30
30
100.00000
Replenished
1001811232
987509358
False
2951969
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000777502
MR00101113
01
02/10/2021
02/10/2021
02/11/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
10
5.55500
Replenished
1001811909
987581092
False
2934336
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000777502
MR00101113
01
02/10/2021
02/10/2021
02/11/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
70
38.88900
Replenished
1001811232
987509358
False
2951967
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000777502
MR00101113
01
02/10/2021
02/10/2021
02/11/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
100
55.55600
Replenished
1001811232
987509358