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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	8090701		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012428	MR00073260	01	12/17/2022	12/17/2022	12/18/2022	65862016001	ZOLPIDEM TARTRATE 10 MG TABLET	10 MG	TABLET	100	30	30	100.00000	Replenished		1002197595	3128646477
False	8417674		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012428	MR00073260	02	01/26/2023	01/26/2023	01/27/2023	65862016001	ZOLPIDEM TARTRATE 10 MG TABLET	10 MG	TABLET	100	30	30	100.00000	Replenished		1002197595	3128646477
False	8703709		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012428	MR00073260	03	02/27/2023	02/27/2023	03/01/2023	65862016001	ZOLPIDEM TARTRATE 10 MG TABLET	10 MG	TABLET	100	30	30	100.00000	Replenished		1002197595	3128646477
False	8978064		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012428	MR00073260	04	03/29/2023	03/29/2023	03/30/2023	65862016001	ZOLPIDEM TARTRATE 10 MG TABLET	10 MG	TABLET	100	30	10	33.33300	Replenished		1002197595	3128646477
False	8984115		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012428	MR00073260	04	03/29/2023	03/29/2023	03/30/2023	65862016001	ZOLPIDEM TARTRATE 10 MG TABLET	10 MG	TABLET	100	30	20	66.66700	Replenished	07/03/2023	1002239529	3138618793
False	9276588		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012428	MR00073260	05	05/01/2023	05/01/2023	05/04/2023	65862016001	ZOLPIDEM TARTRATE 10 MG TABLET	10 MG	TABLET	100	30	30	100.00000	Replenished	07/03/2023	1002239529	3138618793
False	9544264		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012717	MR00073260	00	05/31/2023	05/31/2023	06/01/2023	65862016001	ZOLPIDEM TARTRATE 10 MG TABLET	10 MG	TABLET	100	30	30	100.00000	Replenished	07/03/2023	1002239529	3138618793
False	9825565		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000004012717	MR00073260	01	06/30/2023	06/30/2023	07/01/2023	65862016001	ZOLPIDEM TARTRATE 10 MG TABLET	10 MG	TABLET	100	30	20	66.66700	Replenished	07/03/2023	1002239529	3138618793