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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
5379700
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000784629
MR00398102
02
01/06/2022
01/10/2022
01/11/2022
16571020106
DICLOFENAC SOD EC 75 MG TAB
75 MG
TABLET DR
60
60
60
100.00000
Replenished
1001988245
3079745989
False
5633378
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000784629
MR00398102
03
02/12/2022
02/12/2022
02/13/2022
16571020106
DICLOFENAC SOD EC 75 MG TAB
75 MG
TABLET DR
60
60
60
100.00000
Replenished
1002005236
3083258061
False
5888597
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000789029
MR00398102
00
03/18/2022
03/18/2022
03/19/2022
16571020106
DICLOFENAC SOD EC 75 MG TAB
75 MG
TABLET DR
60
60
60
100.00000
Replenished
1002020832
3086983193
False
6133347
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000789029
MR00398102
01
04/19/2022
04/19/2022
04/20/2022
16571020106
DICLOFENAC SOD EC 75 MG TAB
75 MG
TABLET DR
60
60
60
100.00000
Replenished
1002039367
3090544681
False
7059583
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000792042
MR00398102
00
08/08/2022
08/08/2022
08/09/2022
16571020106
DICLOFENAC SOD EC 75 MG TAB
75 MG
TABLET DR
60
90
60
66.66700
Replenished
1002088256
3102157587
False
7795994
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000792042
MR00398102
01
11/11/2022
11/11/2022
11/12/2022
16571020106
DICLOFENAC SOD EC 75 MG TAB
75 MG
TABLET DR
60
90
60
66.66700
Replenished
1002131051
3112454558
False
7063565
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000792042
MR00398102
00
08/08/2022
08/08/2022
08/09/2022
16571020106
DICLOFENAC SOD EC 75 MG TAB
75 MG
TABLET DR
60
90
30
33.33300
Replenished
1002131051
3112454558
False
7790740
Memorial Hospital
**Trapp Pharmacy (#1)
**Trapp Pharmacy (#1)
Third Party – Captured
000000792042
MR00398102
01
11/11/2022
11/11/2022
11/12/2022
16571020106
DICLOFENAC SOD EC 75 MG TAB
75 MG
TABLET DR
60
90
30
33.33300
Replenished
1002131051
3112454558