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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	9774907		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	03	06/24/2023	06/24/2023	06/25/2023	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished	06/27/2023	1002237550	3138008261
False	9778911		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	03	06/24/2023	06/24/2023	06/25/2023	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished	06/27/2023	1002237550	3138008261
False	9778912		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	03	06/24/2023	06/24/2023	06/25/2023	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33400	Replenished	06/27/2023	1002237550	3138008261
False	3269384		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781051	M8KG365D	00	04/07/2021	04/07/2021	04/08/2021	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished		1001839075	3052306186
False	3276699		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781051	M8KG365D	00	04/07/2021	04/07/2021	04/08/2021	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished		1001839075	3052306186
False	3276700		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000781051	M8KG365D	00	04/07/2021	04/07/2021	04/08/2021	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33400	Replenished		1001839075	3052306186
False	7147368		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792287	MR00108692	00	08/19/2022	08/19/2022	08/20/2022	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	60	60	100.00000	Replenished		1002095700	3103418815
False	7503540		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000792912	MR00108692	00	09/16/2022	09/16/2022	10/07/2022	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	60	60	100.00000	Replenished		1002119397	3108617905
False	7588063		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	00	10/17/2022	10/17/2022	10/18/2022	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished		1002123446	3109811595
False	7595243		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793088	MR00108692	00	10/17/2022	10/17/2022	10/18/2022	69097082103	GEMFIBROZIL 600 MG TABLET	600 MG	TABLET	60	180	60	33.33300	Replenished		1002123446	3109811595