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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
4812691
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000780882
MR00027244
03
10/26/2021
10/26/2021
10/27/2021
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
60
60
100.00000
Replenished
1001961629
3074284779
False
5828921
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000780882
MR00027244
04
03/09/2022
03/09/2022
03/10/2022
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
60
60
100.00000
Replenished
1002020474
3086983191
False
5015903
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000784361
MR00248486
02
11/22/2021
11/22/2021
11/23/2021
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
60
60
100.00000
Replenished
1001963244
3074735172
False
4842289
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000785124
MR00289747
01
10/28/2021
10/28/2021
10/29/2021
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
30
30
100.00000
Replenished
1001961629
3074284779
False
5020124
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000785124
MR00289747
02
11/22/2021
11/22/2021
11/23/2021
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
30
10
33.33300
Replenished
1001986240
3079460588
False
5015911
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000785124
MR00289747
02
11/22/2021
11/22/2021
11/23/2021
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
30
20
66.66700
Replenished
1001963244
3074735172
False
5261250
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000785124
MR00289747
03
12/24/2021
12/24/2021
12/25/2021
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
30
30
100.00000
Replenished
1001986240
3079460588
False
5516913
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000785124
MR00289747
04
01/27/2022
01/27/2022
01/28/2022
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
30
30
100.00000
Replenished
1001996178
3081761727
False
5718801
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000785125
MR00289747
00
02/24/2022
02/24/2022
02/25/2022
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
30
30
100.00000
Replenished
1002020474
3086983191
False
6102411
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000785125
MR00289747
01
04/15/2022
04/15/2022
04/16/2022
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
30
30
100.00000
Replenished
1002039367
3090544681