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Accumulator - View By Claim

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Health Center:

Pharmacy:

Capture Date :

To:

			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	5215880		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786303	MR00389167	01	12/17/2021	12/17/2021	12/18/2021	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002041590	3090640344
False	6157411		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	01	04/22/2022	04/22/2022	04/23/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002041590	3090640344
False	7049033		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	04	08/05/2022	08/05/2022	08/06/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002114625	3108158138
False	7470767		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	06	10/03/2022	10/03/2022	10/04/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002114625	3108158138
False	8256057		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794014	MR00074500	02	01/06/2023	01/06/2023	01/07/2023	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002193992	3127402543
False	8885313		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794014	MR00074500	04	03/20/2023	03/20/2023	03/21/2023	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002193992	3127402543
False	5210212		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786303	MR00389167	01	12/17/2021	12/17/2021	12/18/2021	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished		1001975684	3077386382
False	6161796		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	01	04/22/2022	04/22/2022	04/23/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished		1002062156	3095062963
False	7045016		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	04	08/05/2022	08/05/2022	08/06/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished		1002087483	3101872453
False	7474283		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	06	10/03/2022	10/03/2022	10/04/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished		1002129814	3111983748