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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	3608362		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782115	MR00209146	00	05/21/2021	05/21/2021	05/22/2021	24979002606	DILTIAZEM 24H ER(CD) 120 MG CP	120 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1001862702	3056474257
False	3671953		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782185	MR00117446	00	06/01/2021	06/01/2021	06/02/2021	24979002606	DILTIAZEM 24H ER(CD) 120 MG CP	120 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1001867724	3057523425
False	4007197		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783193	MR00209146	00	07/08/2021	07/08/2021	07/09/2021	24979002606	DILTIAZEM 24H ER(CD) 120 MG CP	120 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1001888054	3061086530
False	4079779		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783355	MR00218313	00	07/19/2021	07/19/2021	07/20/2021	24979002606	DILTIAZEM 24H ER(CD) 120 MG CP	120 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1001891373	3062039555
False	4128167		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783560	MR00139352	00	07/26/2021	07/26/2021	07/27/2021	24979002606	DILTIAZEM 24H ER(CD) 120 MG CP	120 MG	CAP.SR 24H	30	90	30	33.33300	Replenished		1001896238	3062733235
False	4131232		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783560	MR00139352	00	07/26/2021	07/26/2021	07/27/2021	24979002606	DILTIAZEM 24H ER(CD) 120 MG CP	120 MG	CAP.SR 24H	30	90	30	33.33300	Replenished		1001896238	3062733235
False	4131233		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783560	MR00139352	00	07/26/2021	07/26/2021	07/27/2021	24979002606	DILTIAZEM 24H ER(CD) 120 MG CP	120 MG	CAP.SR 24H	30	90	30	33.33400	Replenished		1001896238	3062733235
False	4505297		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000784744	MR00209146	00	09/13/2021	09/13/2021	09/14/2021	24979002606	DILTIAZEM 24H ER(CD) 120 MG CP	120 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1001923041	3067590209
False	4710547		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785438	MR00319594	00	10/11/2021	10/11/2021	10/12/2021	24979002606	DILTIAZEM 24H ER(CD) 120 MG CP	120 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1001939012	3070433439
False	4783684		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000785675	MR00218313	00	10/21/2021	10/21/2021	10/22/2021	24979002606	DILTIAZEM 24H ER(CD) 120 MG CP	120 MG	CAP.SR 24H	30	30	30	100.00000	Replenished		1001946740	3071601882