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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
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
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
4272202
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000781140
MR00225704
01
08/13/2021
08/13/2021
08/14/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
100
55.55600
Replenished
1001903802
3064589183
False
3546044
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000781890
MR00283017
00
05/12/2021
05/12/2021
05/13/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
100
55.55600
Replenished
1001858287
3055645573
False
4318408
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000783706
MR00101113
00
08/18/2021
08/18/2021
08/19/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
100
55.55600
Replenished
1001906178
3065115185
False
4219145
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000783846
MR00283017
00
08/06/2021
08/06/2021
08/07/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
100
55.55600
Replenished
1001900472
3063887831
False
4865088
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000785963
MR00055148
00
11/02/2021
11/02/2021
11/03/2021
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
100
55.55600
Replenished
1001952043
3072719019
False
6999908
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000785963
MR00055148
01
07/29/2022
07/29/2022
07/30/2022
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
100
55.55600
Replenished
1002085673
3101083319
False
7430115
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000793112
MR00117446
00
09/26/2022
09/26/2022
09/27/2022
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
180
100
55.55600
Replenished
1002112616
3107562830
False
7595245
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000793576
MR00117446
00
10/18/2022
10/18/2022
10/19/2022
69315011601
FUROSEMIDE 20 MG TABLET
20 MG
TABLET
100
120
100
83.33300
Replenished
1002123446
3109811595