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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
4522960
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000784825
MR00260341
00
09/15/2021
09/15/2021
09/16/2021
59651026901
GLIPIZIDE ER 5 MG TABLET
5 MG
TAB ER2 24
100
90
90
100.00000
Replenished
1001969736
3076071583
False
5117246
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000784825
MR00260341
01
12/06/2021
12/06/2021
12/07/2021
59651026901
GLIPIZIDE ER 5 MG TABLET
5 MG
TAB ER2 24
100
90
10
11.11100
Replenished
1001969736
3076071583
False
5123555
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000784825
MR00260341
01
12/06/2021
12/06/2021
12/07/2021
59651026901
GLIPIZIDE ER 5 MG TABLET
5 MG
TAB ER2 24
100
90
80
88.88900
Replenished
1001982721
3078646787
False
5811433
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000784825
MR00260341
02
03/07/2022
03/07/2022
03/08/2022
59651026901
GLIPIZIDE ER 5 MG TABLET
5 MG
TAB ER2 24
100
90
30
33.33300
Replenished
1002017255
3085917756
False
5816558
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000784825
MR00260341
02
03/07/2022
03/07/2022
03/08/2022
59651026901
GLIPIZIDE ER 5 MG TABLET
5 MG
TAB ER2 24
100
90
60
66.66700
Replenished
1002040320
3090640343
False
6472588
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000784825
MR00260341
03
06/06/2022
06/06/2022
06/07/2022
59651026901
GLIPIZIDE ER 5 MG TABLET
5 MG
TAB ER2 24
100
90
50
55.55600
Replenished
1002075849
3098184654
False
5309996
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000787323
MR00198270
00
12/30/2021
12/30/2021
12/31/2021
59651026901
GLIPIZIDE ER 5 MG TABLET
5 MG
TAB ER2 24
100
30
10
33.33300
Replenished
1002017255
3085917756
False
5304584
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000787323
MR00198270
00
12/30/2021
12/30/2021
12/31/2021
59651026901
GLIPIZIDE ER 5 MG TABLET
5 MG
TAB ER2 24
100
30
20
66.66700
Replenished
1001982721
3078646787
False
5452712
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000787323
MR00198270
01
01/20/2022
01/20/2022
01/21/2022
59651026901
GLIPIZIDE ER 5 MG TABLET
5 MG
TAB ER2 24
100
30
30
100.00000
Replenished
1002017255
3085917756
False
5689600
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000787323
MR00198270
02
02/21/2022
02/21/2022
02/22/2022
59651026901
GLIPIZIDE ER 5 MG TABLET
5 MG
TAB ER2 24
100
30
30
100.00000
Replenished
1002017255
3085917756