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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	2934116		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000772327	MR00227585	04	01/14/2021	01/14/2021	01/15/2021	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	84	56	66.66700	Replenished		1001796904
False	8859120		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792895	MR00392755	06	03/17/2023	03/17/2023	03/18/2023	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	28	28	100.00000	Replenished		1001796904
False	2934117		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000772327	MR00227585	04	01/14/2021	01/14/2021	01/15/2021	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	84	28	33.33300	Replenished		1001816056	987916714
False	2934115		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776785	MR00392755	02	01/22/2021	01/22/2021	01/23/2021	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	28	28	100.00000	Replenished		1001816056	987916714
False	2976603		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776785	MR00392755	03	02/22/2021	02/22/2021	02/23/2021	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	28	28	100.00000	Replenished		1001816056	987916714
False	3071209		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000778624	MR00373767	01	03/10/2021	03/10/2021	03/11/2021	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	84	84	100.00000	Replenished		1001824882	3049647435
False	3071219		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780454	MR00239553	00	03/10/2021	03/10/2021	03/11/2021	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	84	84	100.00000	Replenished		1001824882	3049647435
False	3151654		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776785	MR00392755	04	03/22/2021	03/22/2021	03/23/2021	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	28	28	100.00000	Replenished		1001831820	3050993427
False	3166415		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780720	MR00391309	00	03/23/2021	03/23/2021	03/25/2021	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	84	56	66.66700	Replenished		1001831820	3050993427
False	3378844		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000776785	MR00392755	05	04/19/2021	04/19/2021	04/20/2021	70700011985	ESTARYLLA 0.25-0.035 MG TABLET	0.25-0.035	TABLET	84	28	28	100.00000	Replenished		1001854421	3055134799