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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	2933766		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779533	MR00386503	00	01/28/2021	01/28/2021	01/29/2021	62332002790	LOSARTAN POTASSIUM 25 MG TAB	25 MG	TABLET	90	30	30	100.00000	Replenished		1001811232	987509358
False	2933765		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779852	MR00162587	00	02/11/2021	02/11/2021	02/12/2021	62332002790	LOSARTAN POTASSIUM 25 MG TAB	25 MG	TABLET	90	90	90	100.00000	Replenished		1001811232	987509358
False	2951923		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779913	MR00018239	00	02/15/2021	02/15/2021	02/16/2021	62332002790	LOSARTAN POTASSIUM 25 MG TAB	25 MG	TABLET	90	90	30	33.33300	Replenished		1001824202	3049524740
False	2948704		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000779913	MR00018239	00	02/15/2021	02/15/2021	02/16/2021	62332002790	LOSARTAN POTASSIUM 25 MG TAB	25 MG	TABLET	90	90	60	66.66700	Replenished		1001811232	987509358
False	3166405		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780008	MR00311967	01	03/24/2021	03/24/2021	03/25/2021	62332002790	LOSARTAN POTASSIUM 25 MG TAB	25 MG	TABLET	90	30	30	100.00000	Replenished		1001838628	3052278967
False	3426497		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780008	MR00311967	02	04/26/2021	04/26/2021	04/27/2021	62332002790	LOSARTAN POTASSIUM 25 MG TAB	25 MG	TABLET	90	30	30	100.00000	Replenished		1001864375	3056859295
False	3628954		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780008	MR00311967	03	05/25/2021	05/25/2021	05/26/2021	62332002790	LOSARTAN POTASSIUM 25 MG TAB	25 MG	TABLET	90	30	30	100.00000	Replenished		1001864375	3056859295
False	3933476		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780008	MR00311967	04	06/30/2021	06/30/2021	07/01/2021	62332002790	LOSARTAN POTASSIUM 25 MG TAB	25 MG	TABLET	90	30	30	100.00000	Replenished		1001883742	3060343039
False	3006952		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780209	MR00386503	00	02/26/2021	02/26/2021	02/28/2021	62332002790	LOSARTAN POTASSIUM 25 MG TAB	25 MG	TABLET	90	30	30	100.00000	Replenished		1001824202	3049524740
False	3061152		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780414	MR00055148	00	03/09/2021	03/09/2021	03/10/2021	62332002790	LOSARTAN POTASSIUM 25 MG TAB	25 MG	TABLET	90	30	30	100.00000	Replenished		1001824202	3049524740