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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	3803208		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782558	MR00013012	00	06/19/2021	06/19/2021	06/20/2021	68001010500	DIVALPROEX SOD ER 250 MG TAB	250 MG	TAB.SR 24H	100	540	40	7.40500	Replenished		1001927749	3068767552
False	3799687		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782558	MR00013012	00	06/19/2021	06/19/2021	06/20/2021	68001010500	DIVALPROEX SOD ER 250 MG TAB	250 MG	TAB.SR 24H	100	540	100	18.51900	Replenished		1001876955	3059092931
False	3803204		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782558	MR00013012	00	06/19/2021	06/19/2021	06/20/2021	68001010500	DIVALPROEX SOD ER 250 MG TAB	250 MG	TAB.SR 24H	100	540	100	18.51900	Replenished		1001876955	3059092931
False	3803205		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782558	MR00013012	00	06/19/2021	06/19/2021	06/20/2021	68001010500	DIVALPROEX SOD ER 250 MG TAB	250 MG	TAB.SR 24H	100	540	100	18.51900	Replenished		1001876955	3059092931
False	3803206		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782558	MR00013012	00	06/19/2021	06/19/2021	06/20/2021	68001010500	DIVALPROEX SOD ER 250 MG TAB	250 MG	TAB.SR 24H	100	540	100	18.51900	Replenished		1001876955	3059092931
False	3803207		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782558	MR00013012	00	06/19/2021	06/19/2021	06/20/2021	68001010500	DIVALPROEX SOD ER 250 MG TAB	250 MG	TAB.SR 24H	100	540	100	18.51900	Replenished		1001876955	3059092931
False	4585060		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782558	MR00013012	01	09/23/2021	09/23/2021	09/24/2021	68001010500	DIVALPROEX SOD ER 250 MG TAB	250 MG	TAB.SR 24H	100	540	60	11.11100	Replenished		1001927749	3068767552
False	4590039		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782558	MR00013012	01	09/23/2021	09/23/2021	09/24/2021	68001010500	DIVALPROEX SOD ER 250 MG TAB	250 MG	TAB.SR 24H	100	540	80	14.81300	Replenished		1001972080	3076588674
False	4590035		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782558	MR00013012	01	09/23/2021	09/23/2021	09/24/2021	68001010500	DIVALPROEX SOD ER 250 MG TAB	250 MG	TAB.SR 24H	100	540	100	18.51900	Replenished		1001927749	3068767552
False	4590036		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000782558	MR00013012	01	09/23/2021	09/23/2021	09/24/2021	68001010500	DIVALPROEX SOD ER 250 MG TAB	250 MG	TAB.SR 24H	100	540	100	18.51900	Replenished		1001927749	3068767552