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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	3403024		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780770	MR00293789	00	04/22/2021	04/22/2021	04/23/2021	60505025203	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	42	42	100.00000	Replenished		1001858287	3055645573
False	3166362		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780710	MR00293789	00	03/23/2021	03/23/2021	03/25/2021	60505025203	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	30	30	100.00000	Replenished		1001858287	3055645573
False	4458951		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783631	MR00293789	00	09/07/2021	09/07/2021	09/08/2021	60505025203	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	30	30	100.00000	Replenished		1001923771	3067867836
False	3077427		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780468	MR00161301	00	03/11/2021	03/11/2021	03/12/2021	60505025203	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1001858287	3055645573
False	3260671		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000780996	MR00161301	00	04/05/2021	04/05/2021	04/07/2021	60505025203	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1001858287	3055645573
False	3440627		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781541	MR00161301	00	04/28/2021	04/28/2021	04/29/2021	60505025203	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1001858287	3055645573
False	3671905		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782293	MR00161301	00	06/01/2021	06/01/2021	06/02/2021	60505025203	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1001923771	3067867836
False	3807083		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782792	MR00161301	00	06/21/2021	06/21/2021	06/22/2021	60505025203	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1001923771	3067867836
False	4018960		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783216	MR00161301	00	07/09/2021	07/09/2021	07/10/2021	60505025203	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1001923771	3067867836
False	4184284		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000783742	MR00161301	00	08/02/2021	08/02/2021	08/03/2021	60505025203	TIZANIDINE HCL 4 MG TABLET	4 MG	TABLET	150	20	20	100.00000	Replenished		1001923771	3067867836