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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
3988901
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011575
MR00210929
00
07/06/2021
07/06/2021
07/07/2021
16729013700
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
90
90
100.00000
Replenished
1001889916
3061619488
False
4050025
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011600
MR00177844
00
07/14/2021
07/14/2021
07/15/2021
16729013700
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
56
10
17.85700
Replenished
1001889916
3061619488
False
4055416
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011600
MR00177844
00
07/14/2021
07/14/2021
07/15/2021
16729013700
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
56
46
82.14300
Replenished
1001890605
3061781566
False
4065252
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011609
MR00152715
00
07/16/2021
07/16/2021
07/17/2021
16729013700
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
90
54
60.00000
Replenished
1001890605
3061781566
False
4070949
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011609
MR00152715
00
07/16/2021
07/16/2021
07/17/2021
16729013700
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
90
36
40.00000
Replenished
1001902816
3064329314
False
4165715
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011635
MR00202849
00
07/30/2021
07/30/2021
07/31/2021
16729013700
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
60
60
100.00000
Replenished
1001902816
3064329314
False
4237847
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011666
MR00210929
00
08/10/2021
08/10/2021
08/11/2021
16729013700
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
90
4
4.44400
Replenished
1001902816
3064329314
False
4458923
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011639
MR00202849
00
09/07/2021
09/07/2021
09/08/2021
16729013700
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
60
14
23.33300
Replenished
1001919113
3067013097
False
4462877
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011639
MR00202849
00
09/07/2021
09/07/2021
09/08/2021
16729013700
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
60
44
73.33300
Replenished
1001919113
3067013097
False
4245929
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011666
MR00210929
00
08/10/2021
08/10/2021
08/11/2021
16729013700
CLONAZEPAM 1 MG TABLET
1 MG
TABLET
100
90
86
95.55600
Replenished
1001919113
3067013097