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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
9822722
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000798877
MR00035389
00
06/29/2023
06/29/2023
06/30/2023
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
90
24
26.66700
Replenished
08/22/2023
1002247471
3140061852
False
9933532
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000799100
MR00030324
00
07/12/2023
07/12/2023
07/13/2023
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
90
76
84.44400
Replenished
08/22/2023
1002247471
3140061852
False
9790076
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000798774
MR00027244
00
06/26/2023
06/26/2023
06/27/2023
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
60
34
56.66700
Replenished
07/03/2023
1002239218
3138618791
False
9817078
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000798877
MR00035389
00
06/29/2023
06/29/2023
06/30/2023
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
90
66
73.33300
Replenished
07/03/2023
1002239218
3138618791
False
9686035
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000796818
MR00030324
03
06/15/2023
06/15/2023
06/16/2023
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
30
30
100.00000
Replenished
06/28/2023
1002238348
3138156842
False
9406122
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000796872
MR00027244
01
05/08/2023
05/08/2023
05/17/2023
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
60
44
73.33300
Replenished
06/28/2023
1002238348
3138156842
False
9787436
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000798774
MR00027244
00
06/26/2023
06/26/2023
06/27/2023
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
60
26
43.33300
Replenished
06/28/2023
1002238348
3138156842
False
8984121
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000792766
MR00035389
02
03/30/2023
03/30/2023
03/31/2023
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
90
24
26.66700
Replenished
05/19/2023
1002221549
3133876132
False
9148381
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000796818
MR00030324
01
04/17/2023
04/17/2023
04/18/2023
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
30
30
100.00000
Replenished
05/19/2023
1002221549
3133876132
False
9375363
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000796818
MR00030324
02
05/15/2023
05/15/2023
05/16/2023
68001039700
FAMOTIDINE 20 MG TABLET
20 MG
TABLET
100
30
30
100.00000
Replenished
05/19/2023
1002221549
3133876132