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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
5015894
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011877
MR00283017
00
11/22/2021
11/22/2021
11/23/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
60
60
100.00000
Replenished
1001964634
3075007286
False
3431002
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011422
MR00051318
00
04/26/2021
04/26/2021
04/27/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
60
50
83.33300
Replenished
1001873947
3058526322
False
3318008
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011391
MR00206514
00
04/14/2021
04/14/2021
04/15/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
45
100.00000
Replenished
1001849254
3054056167
False
3791321
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011536
MR00206514
00
06/18/2021
06/18/2021
06/19/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
45
100.00000
Replenished
1001888398
3061086531
False
4458924
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011718
MR00206514
00
09/07/2021
09/07/2021
09/08/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
45
100.00000
Replenished
1001921962
3067326643
False
4783686
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011820
MR00206514
00
10/21/2021
10/21/2021
10/22/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
45
100.00000
Replenished
1001952718
3073037128
False
5096646
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011900
MR00206514
00
12/03/2021
12/03/2021
12/04/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
45
100.00000
Replenished
1001975684
3077386381
False
4133447
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011629
MR00206514
00
07/27/2021
07/27/2021
07/28/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
45
44
97.77800
Replenished
1001897048
3062863315
False
2958383
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011267
MR00283017
00
02/17/2021
02/17/2021
02/18/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
40
40
100.00000
Replenished
1001826768
3050065355
False
3136405
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011334
MR00283017
00
03/18/2021
03/18/2021
03/19/2021
00591024001
LORAZEPAM 0.5 MG TABLET
0.5 MG
TABLET
100
40
40
100.00000
Replenished
1001834470
3051403571