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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
2957040
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000779878
MR00072992
00
02/16/2021
02/16/2021
02/17/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
90
25
27.77800
Replenished
1001816056
987916714
False
2953784
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000779878
MR00072992
00
02/16/2021
02/16/2021
02/17/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
90
65
72.22200
Replenished
1001811909
987581092
False
2976623
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000780046
MR00095217
00
02/22/2021
02/22/2021
02/23/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
60
15
25.00000
Replenished
1001816056
987916714
False
2978593
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000780046
MR00095217
00
02/22/2021
02/22/2021
02/23/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
60
45
75.00000
Replenished
1001816393
987952822
False
2985853
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000780107
MR00158620
00
02/23/2021
02/23/2021
02/24/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
60
5
8.33300
Replenished
1001824202
3049524740