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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
4968737
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011870
MR00030919
00
11/16/2021
11/16/2021
11/17/2021
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
30
100.00000
Replenished
1002007313
3084006128
False
5181594
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011918
MR00030919
00
12/14/2021
12/14/2021
12/15/2021
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
30
100.00000
Replenished
1002007313
3084006128
False
5386174
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004011973
MR00030919
00
01/11/2022
01/11/2022
01/12/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
30
100.00000
Replenished
1002007313
3084006128
False
5655145
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012034
MR00030919
00
02/15/2022
02/15/2022
02/16/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
10
33.33300
Replenished
1002007313
3084006128
False
5660529
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012034
MR00030919
00
02/15/2022
02/15/2022
02/16/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
20
66.66700
Replenished
1002053268
3093648507
False
5926966
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012090
MR00030919
00
03/22/2022
03/22/2022
03/23/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
30
100.00000
Replenished
1002053268
3093648507
False
6133357
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012090
MR00030919
01
04/20/2022
04/20/2022
04/21/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
30
100.00000
Replenished
1002053268
3093648507
False
6283296
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012163
MR00050302
00
05/10/2022
05/10/2022
05/11/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
1
1
100.00000
Replenished
1002053268
3093648507
False
6349333
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012090
MR00030919
02
05/18/2022
05/18/2022
05/19/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
11
36.66700
Replenished
1002096808
3104187392
False
6343451
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000004012090
MR00030919
02
05/18/2022
05/18/2022
05/19/2022
00378047701
DIAZEPAM 10 MG TABLET
10 MG
TABLET
100
30
19
63.33300
Replenished
1002053268
3093648507