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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	9451167		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794014	MR00074500	06	05/22/2023	05/22/2023	05/23/2023	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	60	100.00000	Replenished	06/29/2023	1002238604	3138299994
False	9793594		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000798839	MR00074500	00	06/27/2023	06/27/2023	06/28/2023	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished	06/29/2023	1002238604	3138299994
False	8890573		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794014	MR00074500	04	03/20/2023	03/20/2023	03/21/2023	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished	05/02/2023	1002210717	3131427601
False	9209533		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000794014	MR00074500	05	04/24/2023	04/24/2023	04/25/2023	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	60	100.00000	Replenished	05/02/2023	1002210717	3131427601
False	4977675		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786303	MR00389167	00	11/17/2021	11/17/2021	11/18/2021	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	60	100.00000	Replenished		1001975684	3077386382
False	5215880		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786303	MR00389167	01	12/17/2021	12/17/2021	12/18/2021	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002041590	3090640344
False	5210212		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000786303	MR00389167	01	12/17/2021	12/17/2021	12/18/2021	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished		1001975684	3077386382
False	5960100		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	00	03/28/2022	03/28/2022	03/29/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	60	100.00000	Replenished		1002041590	3090640344
False	6157411		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	01	04/22/2022	04/22/2022	04/23/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	20	33.33300	Replenished		1002041590	3090640344
False	6161796		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000789092	MR00074500	01	04/22/2022	04/22/2022	04/23/2022	68001015100	CARVEDILOL 12.5 MG TABLET	12.5 MG	TABLET	100	60	40	66.66700	Replenished		1002062156	3095062963