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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	7458156		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786520	MR00389011	10	10/01/2022	10/01/2022	10/02/2022	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	60	100.00000	Replenished		1002119666	3108617906
False	7725640		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786520	MR00389011	11	11/04/2022	11/04/2022	11/06/2022	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	60	100.00000	Replenished		1002129142	3111671677
False	7960380		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794588	MR00389011	00	12/01/2022	12/01/2022	12/03/2022	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	60	100.00000	Replenished		1002150980	3116568653
False	8226429		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794588	MR00389011	01	01/03/2023	01/03/2023	01/04/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	10	16.66700	Replenished		1002167601	3121067798
False	8218047		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794588	MR00389011	01	01/03/2023	01/03/2023	01/04/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	50	83.33300	Replenished		1002156662	3118689060
False	8493340		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794588	MR00389011	02	02/03/2023	02/03/2023	02/04/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	20	33.33300	Replenished		1002178976	3123538684
False	8485419		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794588	MR00389011	02	02/03/2023	02/03/2023	02/04/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	40	66.66700	Replenished		1002170585	3122206860
False	8815068		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796613	MR00389011	00	03/09/2023	03/09/2023	03/10/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	10	16.66700	Replenished		1002199438	3129427833
False	8807335		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796613	MR00389011	00	03/09/2023	03/09/2023	03/10/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	50	83.33300	Replenished		1002187584	3126302342
False	9051468		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796613	MR00389011	01	04/06/2023	04/06/2023	04/07/2023	64980028101	GLIPIZIDE ER 10 MG TABLET	10 MG	TAB ER2 24	100	60	60	100.00000	Replenished		1002199438	3129427833