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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
3746017
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000776639
MR00010529
02
06/01/2021
06/01/2021
06/11/2021
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33300
Replenished
1001873325
3058406861
False
3751351
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000776639
MR00010529
02
06/01/2021
06/01/2021
06/11/2021
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33300
Replenished
1001873325
3058406861
False
3751352
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000776639
MR00010529
02
06/01/2021
06/01/2021
06/11/2021
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33400
Replenished
1001873325
3058406861
False
4592346
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000776639
MR00010529
03
09/23/2021
09/23/2021
09/25/2021
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33300
Replenished
1001928107
3068767554
False
4597597
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000776639
MR00010529
03
09/23/2021
09/23/2021
09/25/2021
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33300
Replenished
1001928107
3068767554
False
4597598
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000776639
MR00010529
03
09/23/2021
09/23/2021
09/25/2021
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33400
Replenished
1001928107
3068767554
False
3048356
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000778294
MR00177615
01
03/05/2021
03/05/2021
03/05/2021
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33300
Replenished
1001822785
3049139689
False
3052155
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000778294
MR00177615
01
03/05/2021
03/05/2021
03/05/2021
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33300
Replenished
1001822785
3049139689
False
3052156
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000778294
MR00177615
01
03/05/2021
03/05/2021
03/05/2021
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33400
Replenished
1001822785
3049139689
False
3688153
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Cash 340B
000000778294
MR00177615
02
06/03/2021
06/03/2021
06/03/2021
50458057930
XARELTO 20 MG TABLET
20 MG
TABLET
30
90
30
33.33300
Replenished
1001868899
3057728019