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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	9276559		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797734	MR00157951	00	05/03/2023	05/03/2023	05/04/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	10	11.11100	Replenished	05/08/2023	1002213418	3132524753
False	9295675		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797734	MR00157951	00	05/03/2023	05/03/2023	05/04/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	80	88.88900	Replenished	05/22/2023	1002221811	3134071093
False	9081904		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000797212	MR00157951	00	04/10/2023	04/10/2023	04/11/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	90	100.00000	Replenished	04/12/2023	1002200467	3129734792
False	8997174		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796556	MR00157951	00	03/07/2023	03/07/2023	03/08/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	10	11.11100	Replenished	04/12/2023	1002200467	3129734792
False	8784360		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796556	MR00157951	00	03/07/2023	03/07/2023	03/08/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	20	22.22200	Replenished		1002186410	3126119732
False	8793071		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796556	MR00157951	00	03/07/2023	03/07/2023	03/08/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	60	66.66700	Replenished		1001765042
False	8552498		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795930	MR00157951	00	02/06/2023	02/06/2023	02/11/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	90	100.00000	Replenished		1002182991	3124681387
False	8363698		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795572	MR00289972	00	01/19/2023	01/19/2023	01/20/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	10	11.11100	Replenished		1002167601	3121067798
False	8353485		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795572	MR00289972	00	01/19/2023	01/19/2023	01/20/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	80	88.88900	Replenished		1002165418	3120576240
False	8237870		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795200	MR00157951	00	01/04/2023	01/04/2023	01/05/2023	68001041200	GABAPENTIN 800 MG TABLET	800 MG	TABLET	100	90	20	22.22200	Replenished		1002165418	3120576240